Advance Decision
By: ________ of
________
Date of Birth: ________
GP:
________ of
________
To whom it may concern,
1. I make this advance decision and it is addressed to any person who may be responsible for my health care in the future, including my family and any healthcare professional.
2. The contents of this advance decision have been carefully created by me of my own free will, while I have the capacity to do so.
3. I have also discussed the contents of this advance decision with my GP.
4. If at any time after I make this advance advance decision:
4.1. I lack capacity to give consent or to refuse consent to healthcare or treatment within the meaning of the Mental Capacity Act 2005; AND
4.2. the Specified Circumstances listed below arise; THEN
4.3. none of the Specified Treatments will be administered to me or continued.
5. 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.
6. The Specified Circumstances are any of the following circumstances (which must be verified and confirmed by at least two qualified medical doctors):
6.1. constant, unremitting pain and there is no real prospect of improvement or recovery;
6.2. I am physically paralysed and there is no reasonable prospect of a substantial recovery ;
6.3. any serious impairment of the mind or brain so that I cannot take care of myself independently and with dignity ;
6.4. unconsciousness or coma from which it is unlikely that consciousness will ever be regained;
6.5. a persistent vegetative state and it is unlikely that their full cognitive functioning will ever be regained
7. In this advance decision Specified Treatments shall mean:
7.1. Cardiopulmonary resuscitation
7.2. Artificial nutrition and hydration
7.3. Artificial Respiration
7.4. The following Specified Treatments shall also include:
________
8. 8 8222 22 2588 5585282 52888822 558 8222 522288225 8825 22 22 52 252 58282 5555288.
9. 5588 5585282 52888822 8522582528 525 5282228 588 25288258 5585282 528888228 2552 82 22 (8522525 255882 25 82 8582822).
SIGNED:
_________________
________
DATED:
_________________
Signed in the presence of:
NAME OF WITNESS:
_________________
SIGNATURE OF WITNESS
_________________
ADDRESS OF WITNESS:
__________________
OCCUPATION OF WITNESS:
__________________
RECORD OF REVIEW:
REVIEWED BY THE DECISION MAKER AS FOLLOWS:
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
Advance Decision
By: ________ of
________
Date of Birth: ________
GP:
________ of
________
To whom it may concern,
1. I make this advance decision and it is addressed to any person who may be responsible for my health care in the future, including my family and any healthcare professional.
2. The contents of this advance decision have been carefully created by me of my own free will, while I have the capacity to do so.
3. I have also discussed the contents of this advance decision with my GP.
4. If at any time after I make this advance advance decision:
4.1. I lack capacity to give consent or to refuse consent to healthcare or treatment within the meaning of the Mental Capacity Act 2005; AND
4.2. the Specified Circumstances listed below arise; THEN
4.3. none of the Specified Treatments will be administered to me or continued.
5. 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.
6. The Specified Circumstances are any of the following circumstances (which must be verified and confirmed by at least two qualified medical doctors):
6.1. constant, unremitting pain and there is no real prospect of improvement or recovery;
6.2. I am physically paralysed and there is no reasonable prospect of a substantial recovery ;
6.3. any serious impairment of the mind or brain so that I cannot take care of myself independently and with dignity ;
6.4. unconsciousness or coma from which it is unlikely that consciousness will ever be regained;
6.5. a persistent vegetative state and it is unlikely that their full cognitive functioning will ever be regained
7. In this advance decision Specified Treatments shall mean:
7.1. Cardiopulmonary resuscitation
7.2. Artificial nutrition and hydration
7.3. Artificial Respiration
7.4. The following Specified Treatments shall also include:
________
8. 8 8222 22 2588 5585282 52888822 558 8222 522288225 8825 22 22 52 252 58282 5555288.
9. 5588 5585282 52888822 8522582528 525 5282228 588 25288258 5585282 528888228 2552 82 22 (8522525 255882 25 82 8582822).
SIGNED:
_________________
________
DATED:
_________________
Signed in the presence of:
NAME OF WITNESS:
_________________
SIGNATURE OF WITNESS
_________________
ADDRESS OF WITNESS:
__________________
OCCUPATION OF WITNESS:
__________________
RECORD OF REVIEW:
REVIEWED BY THE DECISION MAKER AS FOLLOWS:
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
REVIEWED BY ________ ON ______(day) _______ (month) _______(year)
Signed: ___________________________
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