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Advance Care Planning: A Practical Guide for New Jersey Adults

November 12, 2026
Advance Care Planning: A Practical Guide for New Jersey Adults

Advance care planning is the process of deciding what kind of medical care you would want if you became seriously ill or could not speak for yourself, and then telling the people who would need to know. It has two parts: conversations with your loved ones and your doctor, and, if you choose, written documents that put your wishes on record. You do not need to be elderly or sick to start. This guide walks through what the process includes, how to begin the conversation, how the paperwork fits together, and when to revisit your plan.

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TL;DR

  • Advance care planning is mostly conversation. According to the National Institute on Aging, talking with loved ones is the most important part, and written advance directives support it.
  • The two most common advance directives are the living will and the durable power of attorney for health care (in New Jersey materials, the healthcare proxy).
  • A POLST is different: it is a medical order for people who are seriously ill or frail, completed with a health care team.
  • Review your plan at least once a year and after major life changes.
  • Your primary care visit is a natural place to start. We are glad to help you begin that conversation.

Table of Contents

What advance care planning includes

The National Institute on Aging describes advance care planning as discussing and preparing for future decisions about your medical care if you become seriously ill or unable to communicate your wishes. That description covers a few separate steps:

  1. Thinking about what matters to you. This might be staying independent, being comfortable, being at home, or reaching a family event.
  2. Talking with the people involved. That means family, friends, anyone you might name to decide for you, and your doctor.
  3. Choosing a decision maker. This is a person you trust to speak for you if you cannot.
  4. Writing it down. Many people complete advance directives, which are legal documents that record their preferences.
  5. Sharing and reviewing. Copies go to your decision maker, your family and your doctor, and the plan is revisited over time.

Colorado's public health department makes the same point: the process includes advance directive documents as well as ongoing conversations with loved ones and decision makers. A form alone is not a plan. A conversation alone, with nothing written, leaves room for confusion. The two work best together.

The Goals of Care Coalition of New Jersey summarizes the process in three words in its "Let's Talk" guide: discuss, decide, document. It is a simple order to follow, and we use it as the outline for the rest of this article.

Step one: discuss what matters to you

Before you pick a form, work out your goals. Doctors call this a goals-of-care conversation. The idea is simple. The medical literature on identifying goals of care explains that exploring goals ahead of time helps clinicians understand why a patient would choose or decline a particular treatment, and that the goals belong to the patient, or to the person speaking for the patient.

Examples of goals of care

Goals are personal, and there are no right or wrong answers. The New Jersey POLST form lists examples that people commonly name, including longevity or cure, a better quality of life, living long enough to attend a family event, and living without pain, nausea or shortness of breath. It also mentions everyday activities such as eating, driving, gardening and enjoying grandchildren.

Older woman tending plants in her garden

The same form asks "What are your hopes for the future?" and encourages medical providers to share information about prognosis so you can set realistic goals. In other words, a good conversation goes both ways: you share what matters, and your clinician shares what is medically likely.

The goals-of-care literature also describes three broad treatment approaches people choose between:

  • Care focused on keeping you comfortable, with pain and symptom management.
  • An intermediate plan that may include hospitalization, IV medications or monitoring.
  • Full, life-sustaining treatment, such as ventilators, dialysis and major surgery.

You can think about where you fall on that range, and your answer may change with your health. That is one reason the plan gets reviewed.

Talking with family and friends

The Conversation Project offers a conversation starter guide built around the same idea: begin with what matters to you, not with a legal form. A few starting points that work for many families:

  • "If I got very sick, I would want you to know what matters most to me."
  • "Who do you think should speak for me if I couldn't?"
  • "What would you want, if it were you?"

Choose a quiet time, such as a family dinner or a walk, rather than a hospital waiting room. Short, repeated talks usually go better than one long one.

Step two: decide who speaks for you and what you want

Your health care agent or proxy

The most important decision in advance care planning is often who will speak for you. The Conversation Project explains that the health care proxy section of an advance directive names the person you have chosen to make health care decisions on your behalf, plus an alternate. Naming an alternate matters because your first choice may be unavailable when the moment comes.

Pick someone who knows you well, can stay calm under pressure, and is willing to follow your wishes even if they would choose differently. Then talk to that person in detail. A name on a form is much less useful than an agent who understands your values.

Living will vs. advance directive

People often use these terms as if they were the same. They are related, but not identical.

TermWhat it isWhat it does
Advance directiveThe umbrella term for legal documents about future health careRecords your preferences and who decides for you
Living willOne type of advance directiveDescribes the care you would or would not want if you cannot speak for yourself
Health care proxy (durable power of attorney for health care)The other common typeNames the person who makes decisions for you, plus an alternate

The National Institute on Aging calls the living will and the durable power of attorney for health care the two most common advance directives. Many forms combine both parts in one document. So the short answer is that a living will is a kind of advance directive, and an advance directive may include a living will, a proxy designation or both.

What you can put in an advance directive

It can cover a broad range of choices. The California Attorney General's office notes that an advance directive can address end-of-life treatment, diagnostic testing, surgical procedures, cardiopulmonary resuscitation and organ donation. Rules vary by state. In Massachusetts, for example, the health care proxy is the legally accepted form, and the agent acts only after a physician determines and documents that the patient cannot make or communicate decisions. Because details differ, use the forms and instructions for the state where you live.

Step three: document your decisions

Where to get forms

You do not need to spend much. The National Institute on Aging says advance directives can be set up for little or no cost, and it lists places to get forms, including your state attorney general's office, your local Area Agency on Aging (reachable through the Eldercare Locator at 800-677-1116), AARP, the American Bar Association, the National Hospice and Palliative Care Organization, and the VA for veterans. CaringInfo also provides free advance directive forms for each state.

If you live or travel between states

Many families in North Bergen and Secaucus have relatives in New York, Pennsylvania or other states, and some people spend winters elsewhere. CaringInfo warns that one state's directive does not always work in another: some states honor out-of-state directives, some only if they resemble their own law, and some have no clear answer. If you spend significant time in more than one state, complete the forms for each of those states.

Share the paperwork

A document nobody can find does not help. Give copies to your health care agent and alternate, keep one where family can reach it, and ask your doctor's office to add a copy to your chart. Tell the people who matter where it is.

What is a POLST, and who needs one?

A POLST is not the same as an advance directive. National POLST describes it as a portable medical order for people who are seriously ill or have advanced frailty due to aging. It grows out of a conversation between you and your health care team.

It covers three decision areas: whether you want CPR, what kind of care you want (full or intensive, selective, or comfort focused), and what level of medically assisted nutrition you want. Because it is a medical order, it tells emergency responders what life-saving measures you want if you become unresponsive. The New Jersey Department of Health publishes a New Jersey POLST form completed with a practitioner.

If you are generally healthy, an advance directive and a conversation with your proxy are usually the right place to begin. If you live with a serious or advancing illness, ask your doctor whether a POLST makes sense for you.

How to prepare for the conversation with your doctor

The National Institute on Aging has a worksheet of tips for talking with your doctor. Here is how its advice translates into a visit.

Before the visit

  • Write down your current health issues and your questions about future care, including end-of-life care.
  • Decide whether you want someone to come with you.
  • Call or send a message ahead to say you want to discuss advance care planning, so the visit has time set aside.
  • Bring any forms you have started or finished.

During the visit

  • Open with a plain sentence, such as "I want to talk about my goals for care."
  • Talk about your health today and what matters to you.
  • Ask until you have the information you need.

After the visit

  • Plan to discuss your advance directive with your doctor at least once a year and after major life changes.

The New York State Department of Health suggests questions clinicians can use to open the topic, such as "What are your goals for your care?" and "What concerns you most when you think about your health and health care in the future?" You can borrow those questions yourself. If you want more ideas for any appointment, our guide to questions to ask your physician is a good companion.

Advance care planning in primary care

Primary care is a natural home for this work because your doctor knows your history. Comagine Health's implementation guide says advance care planning is a voluntary face-to-face service between a physician or other qualified health care professional and a patient, family member, caregiver or surrogate, and that it is built into the Medicare initial preventive physical exam and the annual wellness visit.

On cost, the New York State Department of Health states that Medicare will pay for advance care planning conversations, either as a separate, medically necessary Part B service or as part of the annual wellness visit, and that other insurers may reimburse as well. Ask your insurer about your own coverage.

The gap between wishes and action is large. The same Comagine guide reports that 80% of people say they would want to talk with their doctor about end-of-life care if seriously ill, while only 7% report having had that conversation in the office. Raising the topic yourself closes that gap. For Medicare beneficiaries, our Medicare wellness checklist for New Jersey seniors shows how the annual visit can fit in.

When to review and update your plan

An advance care plan is not a one-time task. The National Institute on Aging advises treating advance directives as living documents: review them at least once a year, and update them after a major event such as retirement, moving out of state or a significant change in health. Comagine's guide suggests review at a decade birthday, a health change, or annually depending on age.

Good moments to revisit your plan include:

  • A new diagnosis or a change in how a condition is progressing.
  • A hospital stay.
  • Marriage, divorce, or the death of someone named in your documents.
  • A move, whether across state lines or to a different living arrangement.

A change in where you live is often tied to a change in health. If you are helping a parent think through that kind of move, these signs it may be time for assisted living can help families notice when needs have changed, which is also a cue to review the plan and make sure the agent and the documents still fit.

What happens without a plan

If you cannot make decisions and have no advance directive, state law decides who speaks for you. The National Institute on Aging explains that this is typically a spouse, parents if available, or adult children. If none of them is available, some states allow a close friend who knows your values, or a physician acting in your best interests. That default may not match the person you would have chosen, and it gives your family no guidance about your wishes. A short conversation and a signed form can spare them that uncertainty.

Our perspective

We see advance care planning as part of good primary care, not a separate event reserved for the end of life. Our practice combines primary care, cardiopulmonary services, on-site diagnostic testing and health programs focused on prevention and chronic condition management. That mix lets us talk about your wishes in the context of your actual health.

When you manage a condition such as diabetes, heart disease, lung disease or bone loss, your goals shape your care every day. What do you want your treatment to protect: independence, comfort, time with family? Those answers belong in your chart and in your family's hands, not only in a drawer.

We also believe the conversation works best when it is repeated. A visit after a change in health is a better time to revisit your wishes than a crisis. Telemedicine visits can make follow-up easier when getting to the office is hard, and we welcome family members and caregivers to join.

Our advice is simple: pick your health care agent, talk to them, write your preferences down, and bring the paperwork to your next appointment.

Garden State Medical Group

Start the conversation with our team

Garden State Medical Group serves families in North Bergen and Secaucus, including Medicare and Medicaid beneficiaries, with primary care and a range of health programs for chronic conditions, bone health, lung health, memory and more. If you want to discuss your goals for care, mention it when you book, bring any forms you have started, and tell us who you would like to join you. For general check-up planning, see our checklist for annual health exams.

Garden State Medical Group

Visit gardenstatemedicalgroup.com to schedule an appointment.

FAQ

Is advance care planning only for older adults?

No. Any adult can become suddenly unable to make decisions after an accident or illness. The National Institute on Aging notes that a health care proxy and a living will are available to any adult, and that you should update them as life changes. Starting early means your choices are known before anyone has to guess.

Do I need a lawyer to complete an advance directive?

Usually not. The National Institute on Aging says advance directives can be set up for little or no cost, and Colorado's health department notes that its medical power of attorney form can be completed at home without an attorney. Requirements, such as witnesses or notarization, vary by state, so follow the instructions on the form for your state.

What is the difference between an advance directive and a POLST?

An advance directive is a legal document that records your general wishes and names your decision maker, and any adult can complete one. A POLST is a medical order for people who are seriously ill or frail, completed with a health care team, and it guides emergency responders. Many people with serious illness have both.

How often should I review my plan?

At least once a year, and after major life changes such as a new diagnosis, a move or the loss of someone named in your documents. Raise it at your yearly check-up so your doctor can note any changes in your chart.

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