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Advance Healthcare Directive & Conversation Guide

If I am not for myself, FOR YOU:
who will be for me? Complete this form so your healthcare preferences

are clear and your doctors know your Jewish values.

And if I am only FOR YOUR FAMILY:

for myself, Give your family the clarity and comfort

what am I? that they are honoring your wishes.

And if not now, FOR YOUR FUTURE:

when? Don’t wait until illness strikes and quick decisions
must be made. Take the initiative today.
Healthcare Proxy and Directive
PERSONAL INFORMATION Date of Birth:
Name:
Address:
Telephone:
HEALTHCARE PROXY
I designate the Name: GET STARTED NOW OTHER INITIATIVES BY
following person to act Relationship to You:
on my behalf if at any
time I am not able to Cellphone Number:
make or communicate
healthcare decisions Other Number:
for myself: Primary Email:
Other Email: Netivot Conversation Guide A guide to starting important
ALTERNATE 1
HEALTHCARE PROXY (ALTERNATES) PAIN AND RISK TOLERANCE

If the person I value undergoing potentially painful treatments if they have conversations with your family

named above is Name:
unable, unwilling or the potential of prolonging my life—even if they will not cure my

unavailable to act as Relationship to You: underlying illness and may lead to significant discomfort:

my agent, I hereby Cellphone Number: Low Medium
designate: High

I value undergoing potentially painful treatments to try prolonging my Jewish Organ Donation Initiative

life toward the goal of participating in a specific occasion (like a family

ALTERNATE 2 Designate your healthcare
Email Address: ing illness and may lead to significant discomfort:
Other Number: wedding, bar/bat mitzvah, or birth), even if they will not cure my underly-
Name:
Relationship to You: HOSPITAL PRAYERS
It is my medical team’s responsibility to try to balance pain relief
with maintaining my alertness. When it is difficult to maintain
Cellphone Number: Pain relief Alertness proxy and rabbinic consultant
both, I would prefer for them to prioritize: (mark one)
(even if it means I
am not as alert
Other Number: or awake); (even if it means I
may suffer pain and/
Email Address: or other symptoms):
I value undergoing high-risk procedures if it could
www.ematai.org
Possibly cure my underlying illness:
Yes
Navigate Healthcare Choices with Jewish Wisdom No
4 I value undergoing high-risk procedures if it could Communicate your healthcare
Yes RABBINIC TRAINING
Possibly stabilize my condition but not cure my underlying illness:
No
preferences and Jewish values
I value undergoing high-risk procedures if it could
Possibly extend my life by any amount of time (a few days or
weeks) but not cure my underlying illness:
Yes
No
Additional Comments:

EDUCATIONAL RESOURCES
Endorsed by leading Poskim,
II

doctors, and attorneys

Navigate Healthcare Choices with Jewish Wisdom
www.ematai.org
TO LEARN MORE ABOUT NETIVOT: READ THE ARTICLE BY RABBI DR. SHLOMO BRODY IN THIS EDITION OF HAMIZRACHI
REALTIME CONSULT: +1-646-599-3895 www.ematai.org
NAVIGATE YOUR HEALTHCARE JOURNEY WITH JEWISH WISDOM