Introduction

The Netivot healthcare proxy and advance healthcare directive was created by Ematai with the advice of many rabbis, healthcare professionals, social workers, & lawyers. This is a formal legal document that must be signed & witnessed. 

You are encouraged to consult with your own attorney for any questions about your specific needs or local requirements. Nothing in this document constitutes the offer of legal advice from Ematai. 

This multi-state version of the Netivot healthcare proxy & directive is for use in all of the United States. Residents of Texas, Wisconsin, Ohio, & New Hampshire must also attach their state’s mandatory disclosure statement to their healthcare directive. Those documents are available for download on Netivot’s website and should be stored together with the healthcare proxy and directive. 

This digital document is not legally binding until it has been printed and signed before two legal witnesses. After you fill in the necessary information, you will be directed to download the PDF version of this document in order to sign it.

What is a healthcare proxy?

Your healthcare proxy is someone you appoint as your agent to make healthcare decisions on your behalf if you are no longer able to speak for yourself. Even in medical situations that you had not anticipated, your proxy can make decisions and ensure you are treated according to your wishes, values, and beliefs. These are important decisions including:

• What types of treatments you might receive, such as surgeries or dialysis.

• Whether you receive life-support interventions, including resuscitation, intubation, and artificial nutrition.

• Where you receive care, including a hospital, living facility, or your home.

We recommend to designate alternate (backup) proxies on this form in case your primary proxy is unable or unavailable to assist when needed. Only one person should be designated in each of the proxy slots (e.g., do not name a couple or a group as joint proxies.)

Your proxy or alternate proxy should not be an employee at your healthcare institution (unless they are a close blood relative like a spouse), nor someone who professionally evaluates your capacity to make decisions.

Note: Your health care proxy is only designated to serve as your agent regarding decisions of healthcare alone. This document does not appoint them as your “financial power of attorney.” Please speak to your attorney regarding the appointment of a financial power of attorney, who may be the same person as your healthcare proxy, but does not have to be. Your financial agent should be directed to pay for the healthcare decisions made by your healthcare proxy. 

Who should I designate as my proxy?

Choose a proxy who is:

• 18 years or older

• Available (or will make themselves available) at any time when you’ll need them

• Willing to assert themselves to express your wishes and advocate for your needs

• Trustworthy to honor your values and act in accordance with your preferences to the best of their ability.

Think carefully about who those people are amongst your family and friends. Make sure that they are willing to serve in this role before you designate them as your proxy. Please provide on this document as many ways as possible to reach your proxy. Talk to them about your values and preferences regarding healthcare. The Netivot conversation guide will help you in having those conversations. 

Rabbinic Consultant

The Netivot healthcare directive asserts that your proxy’s decisions regarding your healthcare should be done  in  accordance  with Jewish law and custom. What does that mean to you? What interpretation of Jewish law and custom do you want your proxy to apply in these circumstances? These are important questions that relate to your core values.

This option allows you to select a rabbi or institution that can help your proxy make those difficult decisions.

Many people and their families can have different religious perspectives. They might also have multiple rabbinic influences in their lives. A couple, for example, might have relationships with several rabbis while their children each have their own religious mentors or none at all.  This is your opportunity to clarify who you want to be consulted so that your proxy and loved ones do not have to determine (or debate) this in a moment of urgency. 

Before making your choice, talk to the designated rabbi or institution to express your wishes on these sensitive topics and to find out their own perspectives on Jewish medical ethics. Make sure that they are willing to fulfill this role for you and your proxy, as needed, in light of your own preferences and values.

Since rabbis are not available at every moment, or may not remain in their current role at the time they are needed, we encourage you to designate multiple consultants or local institutions, such as your synagogue, in the order of your preference. Ematai’s consultation is always available for help. 

You may designate our hotline (646-599-3895) as an alternate backup, or as a primary consultant if you do not have a rabbi.

If you choose not to designate a rabbi, the section will be left blank and your proxy will decide what standard of Jewish law and custom you would prefer and/or whom to consult.

Note: Your designated healthcare proxy remains the sole authorized decision maker. The rabbi or institution serving as consultants do not have the responsibility or authority to make final decisions or sign any critical documents.

As to the requirements of Jewish law and custom, I advise my proxy to consult with the following rabbi or religious institution.

Organ Donation for Transplantation

A person may elect to donate their organs if they have been declared dead under local legal criteria and the criteria of Jewish law. This section allows you to authorize your proxy to approve transplantation of organs and tissues permissible under Jewish law and custom. You may also express your opposition to organ donation or specify which organs you’d be willing to donate.

This section only authorizes transplantation. It does not authorize donating one’s body for scientific research, medical study, or any other purpose.

Note: Different rabbis have varying criteria for determining  death  under  Jewish  law.  Please consult with the Ematai website and your rabbi for more information. The formulation on the Ematai form allows you to designate yourself as an organ donor without specifying your preferred criteria for death under Jewish law. If you personally have views on that particular question, please express it to your healthcare proxy and record it on your conversation guide.

If you choose not to give an answer, the section will be left blank and your proxy will decide whether or not to donate organs for transplantation.  

The following is the directive (“I Declare”) statement that will be present on the printed version of this advance directive. We have included it here for you to read. It can also be read when you sign the hard copy.

My proxy has full authority to make decisions for me about my health care, including end-of-life care, if I am not able to make or communicate healthcare decisions for myself. This includes my desire, which I hereby direct my proxy, that all decision-making about my healthcare should be done in accordance with Jewish law and custom.

I grant to my proxy all the powers and rights given to a health care agent under law. My proxy is authorized to have access to medical records and information to the same extent that I am entitled. This authority applies to any information governed by any law including the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 USC 132d and 45 CFR 160-164. My proxy is authorized to initiate or defend any legal proceedings related to matters of my healthcare.

My proxy is authorized to make all necessary arrangements for me at any hospital, hospice, nursing home, convalescent home or similar establishment, or home care, including my transfer and removal from any facility, including moving me to another state or country, and to assure that all my essential needs are provided for at such a facility.

My proxy knows my healthcare goals and wishes based on our conversations and on any other general guidance I may have provided. My proxy’s authority to interpret my wishes regarding personal care is intended to be as broad as possible. It includes matters of nutrition, hydration, shelter, clothing, hygiene, safety, and health care, such as (but not limited to) the ability to agree to, refuse, or withdraw consent to any type of medical care, treatment, surgical procedures, tests, or medications.

My proxy has the exclusive ability and authority to make all decisions including those regarding life-sustaining treatment in accordance with my wishes and my proxy’s actions shall be deemed in my best interests. This proxy shall remain in full force and effect at all times, notwithstanding my continued incapacity or disability. I specify that I do not want those decisions to be made on my behalf by any healthcare provider or medical board and that I do not want them to determine what is in my best interests. Should it be deemed necessary to appoint a medical conservator or guardian, I request the court to appoint my proxy to this role.

Handling of My Body After Death: All decisions concerning the handling and disposition of my body and preparation for burial, including removal of tubes, catheters, IV lines, cardiac devices and cleaning of the body, are to be made pursuant to Jewish law and custom as authorized by my proxy. It is my desire, and I hereby direct, that to the extent permitted by law, no post-mortem procedure be performed on my body unless authorized by my proxy. If the law requires, I request the least invasive procedures possible be used to comply with the minimum legal requirements in respect of my religious wishes, and that burial take place as soon as possible.

It is my express wish for the decisions of my proxy to be honored. I trust my proxy’s ability to understand what my wishes and best interests would be in every instance, including my desire that all decision-making about my healthcare should be done in accordance with Jewish law and custom.

This digital document is not legally binding until it has been printed and signed before two legal witnesses (or a notary if your state requires it). 

Your two witnesses must be adults and may not be:

• the person appointed as agent or alternate agent or your rabbinic consultant
• financially responsible for your health care
• a creditor of the signee or entitled to any part of your estate under a will or codicil, trust, insurance policy, or by operation of intestate succession laws
• entitled to benefit financially in any other way after you die.
• your healthcare provider, including the owner, operator, or employee
  of a health, long-term care, or other residential or community care facility serving you
• related by blood, marriage, domestic partnership, or adoption, nor a spouse of any such person