Advance Decision
By: ________ of
________
Date of Birth: ________
GP: ________ of
________
To whom it may concern,
1. This advance decision is addressed to my family, my doctor and each and every person who may be involved in providing health care to me.
2. The contents of this advance decision have been carefully considered and understood by me and I have the capacity to make the decisions contained in this document.
3. I have also discussed the contents of this advance decision with:
________
________
4. To avoid any doubt, and unless stated to the contrary below, I confirm that the refusal(s) of treatment contained in this advance decision are to apply even if my life is at risk or may be shortened as a result.
5. I hereby declare that at any time after the making of this advance decision when I lack capacity to give or refuse consent to health care treatment or the continuation of such treatment:
A. I refuse the "specified treatments" (detailed below) aimed at prolonging or artificially sustaining my life in any of the following circumstances even if (in the opinion of any person providing health care for me) such treatment is necessary to sustain life (and accordingly this advance decision shall apply to such treatment even if my life is at risk):
I. constant, unremitting pain;
II. any physical illness from which there is no real possibility of recovery and from which it is likely that death will result;
III. any serious impairment of the mind or brain with little or no prospect of recovery;
IV. unconsciousness or coma from which it is unlikely that consciousness will ever be regained;
V. a persistent vegetative state or minimal consciousness and it is unlikely that consciousness will ever be regained
B. In this advance decision 'specified treatments' means any of the following treatments:
I. Cardiopulmonary resuscitation;
II. Electroconvulsive therapy;
III. Artificial nutrition and hydration;
IV. Artificial Respiration
6. 8 8222 22 2588 5585282 52888822 558 8222 522288225 8825 22 22 52 252 58282 5555288.
7. 5588 5585282 52888822 8522582528 525 5282228 588 25288258 5585282 528888228 2552 82 22 (8522525 255882 25 82 8582822).
Signature of ________
Signed: ___________________________
Date:
Witnessed by:
Signed:___________________________
Print Name: ___________________________
Address:
Date:
Reviewed by the maker on:
Signed: ___________________________
Name: ________
Date:
Signed: ___________________________
Name: ________
Date:
Signed: ___________________________
Name: ________
Date:
Signed: ___________________________
Name: ________
Date:
Advance Decision
By: ________ of
________
Date of Birth: ________
GP: ________ of
________
To whom it may concern,
1. This advance decision is addressed to my family, my doctor and each and every person who may be involved in providing health care to me.
2. The contents of this advance decision have been carefully considered and understood by me and I have the capacity to make the decisions contained in this document.
3. I have also discussed the contents of this advance decision with:
________
________
4. To avoid any doubt, and unless stated to the contrary below, I confirm that the refusal(s) of treatment contained in this advance decision are to apply even if my life is at risk or may be shortened as a result.
5. I hereby declare that at any time after the making of this advance decision when I lack capacity to give or refuse consent to health care treatment or the continuation of such treatment:
A. I refuse the "specified treatments" (detailed below) aimed at prolonging or artificially sustaining my life in any of the following circumstances even if (in the opinion of any person providing health care for me) such treatment is necessary to sustain life (and accordingly this advance decision shall apply to such treatment even if my life is at risk):
I. constant, unremitting pain;
II. any physical illness from which there is no real possibility of recovery and from which it is likely that death will result;
III. any serious impairment of the mind or brain with little or no prospect of recovery;
IV. unconsciousness or coma from which it is unlikely that consciousness will ever be regained;
V. a persistent vegetative state or minimal consciousness and it is unlikely that consciousness will ever be regained
B. In this advance decision 'specified treatments' means any of the following treatments:
I. Cardiopulmonary resuscitation;
II. Electroconvulsive therapy;
III. Artificial nutrition and hydration;
IV. Artificial Respiration
6. 8 8222 22 2588 5585282 52888822 558 8222 522288225 8825 22 22 52 252 58282 5555288.
7. 5588 5585282 52888822 8522582528 525 5282228 588 25288258 5585282 528888228 2552 82 22 (8522525 255882 25 82 8582822).
Signature of ________
Signed: ___________________________
Date:
Witnessed by:
Signed:___________________________
Print Name: ___________________________
Address:
Date:
Reviewed by the maker on:
Signed: ___________________________
Name: ________
Date:
Signed: ___________________________
Name: ________
Date:
Signed: ___________________________
Name: ________
Date:
Signed: ___________________________
Name: ________
Date:
Answer the question, then click on "Next".
The document is written according to your responses - clauses are added or removed, paragraphs are customised, words are changed, etc.
At the end, you will immediately receive the document in Word and PDF formats. You can then open the Word document to modify it and reuse it however you wish.
You will also have the option of requesting assistance from a lawyer.
