Jewish Law
Halachic Forms
    -- Halachic Living Will (Tennessee)

1. Appointment of Attorney-in-Fact: In recognition of the fact that there may come a time when I will become unable to make my own health care decisions because of illness, injury or other circumstances, I hereby appoint

Name of Agent: ___________________________________


Address: _________________________________________


	 _________________________________________


Telephone: Day _________________ Evening _________

as my health care agent to make any and all health care decisions for me, consistent with my wishes as set forth in this directive, and subject to any specific requirements and limitations of applicable law.

If the person named above is unable, unwilling or unavailable to act as my agent, I hereby appoint

Name of Alternate Attorney-in-fact: ______________


Address: _________________________________________


	 _________________________________________


Telephone: Day _________________ Evening _________

to serve in such capacity.

This appointment shall take effect in the event I become unable, because of illness, injury or other circumstances, to make my own health care decisions.

I direct that my agent comply with the following instructions and limitations:

2. Jewish Law to Govern Health Care Decisions: I am Jewish. It is my desire, and I hereby direct, that all health care decisions made for me be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. By way of example, and without limiting in any way the generality of the foregoing, it is my wish that Jewish law and custom should dictate the course of my health care with respect to such matters as the performance or non-performance of cardio-pulmonary resuscitation if I suffer cardiac or respiratory arrest; the initiation or discontinuance of any particular course of medical treatment or other form of life-support maintenance, including tube-delivered nutrition and hydration; and the method and timing of determination of death.

3. Ascertaining the Requirements of Jewish Law: In order to effectuate my wishes, if any question arises as to the requirements of Jewish law and custom in connection with this declaration, I direct my agent to consult with and follow the guidance of the following Orthodox Rabbi:

Name of Rabbi: ___________________________________


Address: _________________________________________


	 _________________________________________


Telephone: Day _________________ Evening _________

If such rabbi is unable, unwilling or unavailable to provide such consultation and guidance, then I direct my agent to consult with and follow the guidance of an Orthodox Rabbi referred by the following Orthodox Jewish institution or organization:

Name of Institution/Organization: ________________


Address: _________________________________________


	 _________________________________________


Telephone: Day _________________ Evening _________

If such institution or organization is unable, unwilling or unavailable to make such a reference, or if the rabbi referred by such institution or organization is unable, unwilling or unavailable to provide such guidance, then I direct my health care decision-maker to consult with and follow the guidance of an Orthodox Rabbi whose guidance on issues of Jewish law and custom my health care decision-maker in good faith believes I would respect and follow.

4. Direction to Health Care Providers: Any health care provider shall rely upon and carry out the decisions of my attorney-in-fact, and may assume that such decisions reflect my wishes and were arrived at in accordance with the procedures set forth in this directive, unless such health care provider shall have good cause to believe that my attorney-in-fact has not acted in good faith in accordance with my wishes as expressed in this directive.

If the persons designated in paragraph 1 above as my attorney-in-fact and alternate attorney-in-fact are unable, unwilling or unavailable to serve in such capacity, it is my desire, and I hereby direct, that any health care provider or other person who will be making health care decisions on my behalf follow the procedures outlined in paragraph 3 above if any questions of Jewish law and custom should arise.

Pending contact with the attorney-in-fact and/or rabbi described above, it is my desire, and I hereby direct, that all health care providers undertake all essential emergency and/or life sustaining measures on my behalf.

5. Post-Mortem Decisions: It is also my desire, and I hereby direct, that after my death, all decisions concerning the handling and disposition of my body be made pursuant to Jewish law and custom as determined in accordance with strict Orthodox interpretation and tradition. By way of example, and without limiting in any way the generality of the foregoing, it is my wish that there be conformance with Jewish law and custom with respect to such matters and questions as whether there exist exceptional circumstances that would permit an exception to the general prohibition under Jewish law against the performance of an autopsy or dissection of my body; the permissibility or non-permissibility of the removal and usage of any of my body organs or tissue for transplantation purposes; and the expeditious burial of my body and all preparations leading to burial.

Time is of the essence with regard to these questions. I therefore direct that any health care provider in attendance at my death notify the attorney-in-fact and/or rabbi described above immediately upon my death, in addition to any other person whose consent by law must be solicited and obtained prior to the use of any part of my body as an anatomical gift, so that appropriate decisions and arrangements can be made in accordance with my wishes. Pending such notification, it is my desire, and I hereby direct, that no autopsy, dissection or other post-mortem procedure be performed on my body.

6. Incontrovertible Evidence of My Wishes: If, for any reason, this document is deemed not legally effective as a durable power of attorney for health care and living will, or if the persons designated in paragraph 1 above as my attorney-in-fact and alternate attorney-in-fact are unable, unwilling or unavailable to serve in such capacity, I declare to my family, my doctor and anyone else whom it may concern that the wishes I have expressed herein with regard to compliance with Jewish law and custom should be treated as incontrovertible evidence of my intent and desire with respect to all health care measures and post-mortem procedures; and that it is my wish that the procedure outlined in paragraph 3 above should be followed if any questions of Jewish law and custom should arise.

7. Severability: In the event that any provision of this directive shall be held invalid or unenforceable, it shall not in any way invalidate, affect, or impair the remaining provisions of this directive, it being my intention that this directive shall be enforced to the extent permitted by law.

8.Duration and Revocation: It is my understanding and intention that unless I revoke this durable power of attorney for health care and living will, it will remain in effect indefinitely. My signature on this document shall be deemed to constitute a revocation of any prior durable power of attorney for health care, living will or other similar document I may have executed prior to today's date.

Date: ________________________


Signature: _______________________________________


Residing at ______________________________________
[address]

(Note: This document will not be valid under Tennessee law unless it is signed and acknowledged before a notary public by the principal (the person who executes the document) and two witnesses.

I declare under penalty of perjury under the laws of Tennessee that the person who signed this document is personally known to me to be the principal; that the principal signed this durable power of attorney for health care and living will in my presence; that the principal appears to be of sound mind and under no duress, fraud or undue influence; that I am not the person appointed as attorney-in-fact by this document; that I am not a health care provider, an employee of a health care provider, the operator of a health care institution, nor an employee of an operator of a health care institution; that I am not related to the principal by blood, marriage, or adoption; that, to the best of my knowledge, I do not, at the present time, have a claim against any portion of the estate of the principal upon the principal's death; and that, to the best of my knowledge, I am not entitled to any part of the estate of the principal upon the death of the principal under a will or codicil now existing, or by operation of law.

In addition, I declare that I am not the principal's attending physician nor an employee of the attending physician; nor an employee of a health care facility in which the declarant is a patient.

Witness ____________________ _____________________
                (Print Name)           (Signature)


Residing at:______________________________________
                                         (Address)


 	
Witness ____________________ _____________________
                (Print Name)           (Signature)


Residing at:______________________________________
                                         (Address)

STATE OF TENNESSEE

COUNTY OF ___________________

Subscribed, sworn to and acknowledged before me by ______________, the declarant, and subscribed and sworn to before me by _________________ and _____________, witnesses, this _____________ day of __________________, in the year _______.

__________________________________________
Notary Public

SEAL

This is an important legal document. Before executing this document you should know these important facts.

This document gives the person you designate as your agent (the attorney in fact) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document.

Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.

Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.

This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose or treat a physical or mental condition. This power is subject to any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent: (1) authorizes anything that is illegal; or (2) acts contrary to your desires as stated in this document.

You have the right to revoke the authority of your agent by notifying your agent or your treating physician, hospital or other health care provider orally or in writing of the revocation.

Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document.

Unless you otherwise specify in this document, this document gives your agent the power after you die to: (1) authorize an autopsy; (2) donate your body or parts thereof for transplant or therapeutic or educational or scientific purposes; and (3) direct the disposition of your remains.

If there is anything in this document that you do not understand, you should ask an attorney to explain it to you.

Note: The text of this document was prepared more than ten years ago. We therefore recommend you consult with a local estates and trusts attorney before executing this document to ensure that it conforms to current state law. Agudath Israel is in the process of updating the Halachic Living Wills for most states.