Jewish Law
Halachic Forms
    -- Halachic Living Will (Instructions for Nebraska)

(a) Please print your name on the first line of the form.

Note: This form is effective only if you are a competent adult (an adult is a person 19 years of age or older, or a person who is or has been married).

(b) In section 1, print the name, address, and day and evening telephone numbers of the person you wish to designate as your agent (known under Nebraska law as your "attorney in fact") to make medical decisions on your behalf if, G-d forbid, you ever become incapable of making them on your own.

You may also insert the name, address, and telephone numbers of an alternate agent (known under Nebraska law as your "successor attorney in fact") to make such decisions if your main agent is unable, unwilling, or unavailable to make such decisions.

It is recommended that before appointing anyone to serve as your agent or alternate agent you should ascertain that person's willingness to serve in such capacity. In addition, if you have made arrangements with a burial society ("Chevra Kadisha") for the handling and disposition of your body after death, you may wish to advise your agents of such arrangements.

Note: Nebraska law allows virtually any competent adult to serve as a health care agent.

You may not, however, appoint your attending physician; an employee of your attending physician (unless the employee is related to you by blood, marriage, or adoption); a person who is an owner, operator, or employee of a health care facility in which you are patient or resident (unless he or she is related to you); or a person who has already been appointed to serve as an agent by ten or more people (unless that person is related to you) to serve as your agent.

(c) In section 3, please print the name, address, and telephone numbers of the Orthodox rabbi whose guidance you want your agent to follow, should any questions arise as to the requirements of halacha.

You should then print the name, address, and telephone numbers of the Orthodox Jewish institution or organization you want your agent to contact for a referral to another Orthodox Rabbi if the rabbi you have identified is unable, unwilling or unavailable to provide the appropriate consultation and guidance.

You are of course free to insert the name of any Orthodox rabbi or institution/organization you would like, but before doing so it is advisable to discuss the matter with the rabbi or institution/organization to ascertain their competency and willingness to serve in such capacity.

(d) At the conclusion of the form, print the date, sign your name, and print your address.

(e) Two witnesses should sign their names and insert their addresses beneath your signature. These two witnesses must be competent adults. Neither of them may be:

1- the person you have appointed as your health care agent (or alternate agent);
2- your spouse, parent, child, grandchild, or sibling;
3- your presumptive heir or a person who is entitled to any part of your estate upon your death;
4- your attending physician; or
5- an employee of your life or health care insurance provider.

At least one witness may not be an administrator or employee of a health care provider who is caring for or treating you.

(f) It is recommended that you keep the original of this form among your valuable papers; and that you distribute copies to the health care agent (and alternate agent) you have designated in section 1, to the rabbi and institution/organization you have designated in section 3, as well as to your doctors, your lawyer, and anyone else who is likely to be contacted in times of emergency.

(g) You may revoke the Proxy and Directive at any time and in any manner by which you can communicate your intent to revoke it.

If you do not revoke the Proxy and Directive, it will remain in effect indefinitely. Obviously, if any of the persons whose names you have inserted in the Proxy and Directive dies or becomes otherwise incapable of serving in the role you have assigned, it would be wise to execute a new Proxy and Directive.

(h) It is recommended that you also complete the second component of the Halachic Living Will, the "Emergency Instructions Card," and carry it with you in your wallet or billfold.

(i) If, upon consultation with your rabbi, you would like to add to this standardized Proxy and Directive any additional expression of your wishes with respect to medical and/or post-mortem decisions, you may do so by attaching a "rider" to the standardized form. If you choose to do so, or if you have any other questions concerning this form, please consult an attorney.