Back to top

Advance Decision to Refuse Treatment

Progress:
0%
?
X

Please enter both the first name and surname of the person making the advance decision.

Need
help?
Customise the template

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 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 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):

b. In this advance decision 'specified treatments' means any of the following treatments:

6. B acdp cb fafa cbecbaa baafafcb aca aaab badcaffab affa ap BB cf faa cacea cbbfaaa.

7. Fafa cbecbaa baafafcb abdafaabaa cbb faecaaa cff dfaefcba cbecbaa baafafcba acba ap aa (aaafaaf cfcffp cf fb affffbd).




Signed:





...................................

Date:.........................

Name: ________



Witnessed by:




Signed:.......................

Date:.........................

Name:.........................



Signed:.......................

Date:.........................

Name:.........................




Signed:.......................

Date:.........................

Name:.........................



Reviewed by the maker on:




Signed:...................................

Date:.........................

Name: ________




Signed:...................................

Date:.........................

Name: ________




Signed:...................................

Date:.........................

Name: ________




Signed:...................................

Date:.........................

Name: ________

See your document in progress

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 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 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):

b. In this advance decision 'specified treatments' means any of the following treatments:

6. B acdp cb fafa cbecbaa baafafcb aca aaab badcaffab affa ap BB cf faa cacea cbbfaaa.

7. Fafa cbecbaa baafafcb abdafaabaa cbb faecaaa cff dfaefcba cbecbaa baafafcba acba ap aa (aaafaaf cfcffp cf fb affffbd).




Signed:





...................................

Date:.........................

Name: ________



Witnessed by:




Signed:.......................

Date:.........................

Name:.........................



Signed:.......................

Date:.........................

Name:.........................




Signed:.......................

Date:.........................

Name:.........................



Reviewed by the maker on:




Signed:...................................

Date:.........................

Name: ________




Signed:...................................

Date:.........................

Name: ________




Signed:...................................

Date:.........................

Name: ________




Signed:...................................

Date:.........................

Name: ________