Advance Decision template (Celia Kitzinger)

 

ADVANCE DECISION

 

To Health Care Professionals: 

 

I, [YOUR NAME], of [YOUR ADDRESS], have the capacity to make the decisions set out in this document.  I have carefully considered how I wish to be treated if, in the future, I lose the capacity to consent to medical treatment, or the ability effectively to communicate my refusal or consent. 

 

Date of birth:  [YOUR DOB]

NHS number:  [YOUR NHS NUMBER]

National Insurance Number:  [YOUR NI NUMBER]

 

REFUSAL OF TREATMENT

To avoid any doubt, and unless stated to the contrary below, I confirm that the following refusals of treatment are to apply even if my life is at risk or may be shortened by virtue of such refusal.

 

In the event that I am no longer competent to make decisions on my own behalf, these are the decisions I have made in advance.  If I lack mental capacity and also have an advanced disseminated malignant disease, advanced degenerative disease of the nervous system (including MS, motor neurone disease and Parkinson’s disease), moderate or severe brain damage due to injury, stroke, disease or other cause, senile or pre-senile dementia, severe difficulty in breathing (dyspnoea) that cannot be cured, or any other condition of comparable gravity, I refuse any medical intervention aimed at prolonging or sustaining my life.

 

In the event of any of the above conditions applying, I refuse all life-prolonging treatments, including but not limited to: cardio-pulmonary resuscitation, artificial ventilation, specialised treatments for particular conditions such as chemotherapy or dialysis, antibiotics when given for a potentially life-threatening infection, and artificial hydration and nutrition.  I also refuse all life-sustaining treatments including but not limited to therapies whose purpose is to maintain or replace a vital bodily function and without which death would most likely occur as a result of organ or system failure.

 

I recognise that I am unlikely specifically to have included all possible current or future treatments for whatever health condition may lead to the applicability of this AD. Nonetheless I wish to refuse them.  Furthermore I am unable to anticipate all possible circumstances under which this AD might become applicable but believe that any such circumstances would be extremely unlikely to alter my decision had I anticipated them.  I am very anxious that new treatments or unpredictable circumstances might be used by my healthcare team to argue that this AD is not applicable and not binding.  I wish so far as I can to pre-empt any such arguments.

 

CONSENT TO TREATMENT

I do consent to any medical treatment to alleviate pain or distress (including any caused by lack of food or fluid) aimed at my comfort.  I do consent to palliative treatment for incurable vomiting or feeling sick (but not for treating any underlying condition causing these symptoms).  I maintain this request even in the event that it may shorten my life.

 

Upon my death I wish to donate all usable organs and I consent to any treatment which is designed to make this possible and to optimise the process.

 

 

I have deposited this advance decision with:

 

1.  My GP: [GP NAME, GP ADDRESS]

 

 

Signed:  ______________________    Date: __________________

 

 

 

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Witness 1   

 

Witness Name :  _________________________

 

Address:            __________________________

 

 

I witness that this advance decision was signed or acknowledged in my presence.

 

 

Signature:   _________________     Dated:    _________________

 

 

 

Witness 2

 

Witness Name :  _________________________

 

Address:            __________________________

 

 

I witness that this advance decision was signed or acknowledged in my presence.

 

 

Signature:   _________________     Dated:    _________________