COMBINED ADVANCE DIRECTIVE FOR HEALTH CARE (COMBINED PROXY AND INSTRUCTION DIRECTIVE) STATEMENT OF BELIEF Catholics believe

that life is a gift of a loving God. Life is a holy gift for which we are responsible, but do not own. We believe that assisted death and suicide destroy human life and are never allowed. As an adult, I have the right to make decisions about my health care. As a Catholic, I may never choose my own death as an end or a means. There may come a time when I am unable to express my own health care decisions. By writing an advance directive, I give instructions and wishes for my future health care decisions. This advance directive for health care shall take effect when I am not able to express my health care decisions, as determined by my attending doctor. I direct that those responsible for my care make health care decisions according to my stated wishes. I direct that this advance directive be included in my permanent medical record. Part One: Naming My Health Care Representative (A) I have chosen the following person to be my Health Care Representative. Name: [name of health care representative] Address: [street address of health care representative] City: [name of city] State: New Jersey Zip: [zip code of area] Telephone Number: [telephone number of health care representative] He will be my health care representative to make my health care decisions when I am not able to speak for myself. If my wishes are not clear or events take place that I have not talked about, I ask that my health care representative make the decisions based upon what he knows of my

wishes. I have talked with my health care representative about this responsibility. He has willingly agreed to accept this role. (B) I have chosen the following person as my Alternate Health Care Representative, if the person I have chosen above is not able, not willing, or not available to act as my health care representative: 1. Name: [name of alternate health care representative] Address: [street address of alternate health care representative] City: [name of city] State: New Jersey [name of state] Zip: [zip code of area] Telephone Number: [telephone number of alternate health care representative] He will be my health care representative to make my health care decisions when I am not able to speak for myself. If my wishes are not clear or events take place that I have not talked about, I ask that my health care representative make the decisions based upon what he knows of my wishes. I have talked with my health care representative about this responsibility. He has willingly agreed to accept this role. Part Two: Treatment Choice Instructions GENERAL INSTRUCTIONS: I direct the people who are responsible for my care to carry out the following: Initial one of the following statementseither A or B.[EITHER, NOT BOTH:] (___) A. I direct that all medically indicated treatments and food and water (through tubes if necessary) be given to maintain my life, no matter what my physical or mental condition. (If you choose A, skip B & C) [OR:]

(___) B. If a serious health condition occurs and my primary doctor and at least one other doctor, who has personally examined me, decide that the irreversible process of dying has begun and death is very near, I direct not to have treatments that would only prolong my dying. If these treatments have been started, they should be stopped. I also want to be given all necessary medical care appropriate to stop pain and to make me comfortable. (If you choose B, go to C) (___) C. If I have been diagnosed as being in a permanent coma or in a persistent vegetative state after being examined by my primary doctor and at least one other doctor who is qualified to make this decision, choose either 1 or 2.[EITHER:] (___) 1. I direct that extraordinary* medical care, as understood in the teachings of the Catholic Church, including food and water (through tubes if needed) shall be used no matter what my physical or mental health.[OR:] (___) 2. I direct that extraordinary* medical care, as understood in the teachings of the Catholic Church, shall not be used. I direct that food and water (through tubes if needed) be continued unless or until the benefits of this food and water are clearly outweighed by a definite danger or burden, or are useless. * Extraordinary medical care is understood as those medicines, treatments or operations which may be very expensive, may cause excessive pain or other extreme difficulties or which may offer no reasonable hope of benefit. Examples of extraordinary measures that I would want are as follows: _ _ [Description of extraordinary measures]

D. If I am pregnant and I am diagnosed as being in a permanent coma, in a persistent vegetative state or that the process of dying has begun and death is near, I direct that all medically indicated measures and food and water (through tubes if necessary) be given to maintain my life, regardless of my physical or mental condition, if this could maintain the life of my unborn child until birth. E. The State of New Jersey recognizes the irreversible cessation of all functions of the entire brain, including the brain stem (also known as whole brain death), as a legal standard for the declaration of death. Generally, physicians will follow this standard. However, if you cannot accept this standard because of your personal religious beliefs, you may request that it not be applied in determining your death by initialing the following statement: ___ To declare my death on the basis of the irreversible cessation of all functions of the entire brain, including the brain stem, would violate my personal religious beliefs. I therefore direct that my death be declared solely on the basis of the traditional criteria of irreversible cessation of cardiopulmonary [OPTIONAL: heartbeat and breathing] function. F. Please initial one: (___) Upon my death, I am willing to donate any parts of my body that may be beneficial to others. (___) Upon my death, I am not willing to donate any parts of my body that may be beneficial to others. Part Three: Signature, Witnesses and Copies A. Signature: By writing this advance directive, I ask that my wishes as stated be put into effect by those people indicated to make health care decisions for me when I can no longer make them for myself. I have talked about the terms of this agreement with my health care representative. He has willingly agreed to accept the responsibility for making decisions for me according to this advance directive. I understand the purpose and effect of this document. I am signing it willfully,

voluntarily, and after careful consideration. Signed today on (month, day, year) [date of execution] Signature _ Name (print name) _ Address _ City _ State: New Jersey B. Witnesses: I state that the person who signed this document above did so in my presence, and appears to be of sound mind and free of duress or undue influence to complete this advance directive. I am 18 years of age or older and am not designated by this or any other document as this person's health care representative. 1. Witness signature Date ______________________ Print witness name ______________________ Address _______________________ City __________________________ State: New Jersey 2. Witness signature: Date ______________________ Print witness name ______________________ Address _______________________ City __________________________ State: New Jersey

C. COPIES: A copy of this advance directive has been given to the following people. (It is important to provide your doctor, your health care representative, and appropriate family members or friends with a copy of this document. You keep the original.) 1. Name [name of individual copied 1] Address [street address of individual copied 1] City [name of city] State: New Jersey Telephone number [telephone number of individual copied 1] 2. Name [name of individual copied 2] Address [street address of individual copied 2] City [name of city] State: New Jersey Telephone number [telephone number of individual copied 2] A COPY OF THIS DIRECTIVE SHOULD BE GIVEN TO YOUR HEALTH CARE REPRESENTATIVE, DOCTOR, AND APPROPRIATE FAMILY MEMBERS OR FRIENDS