Advance Directive Form




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Advance Directive

It is my express wish that if I should develop:

a) senile, severe degenerative brain disease (due to Alzheimer’s disease, arterial disease, AIDS, or other agency) or

b) serious brain damage resulting from accidental or other injury or illness or 

c) advanced or terminal malignant disease or

d) severely  incapacitating and progressive degenerative disease of the nerves or muscles

and have become mentally incompetent to express my opinion about accepting or declining life sustaining treatment, and if two independent physicians conclude that, to the best of current medical knowledge, my condition is irreversible then the following points should be taken into consideration:

  • In the event of a cardiac arrest, regardless of the cause, I should not be given cardiopulmonary resuscitation
  • Any separate illness – for example, pneumonia or a heart or kidney condition – that may threaten my life should not be given active treatment unless it appears to be causing me undue physical suffering
  • During such an advanced illness, if I should become unable to swallow food, fluid, or medication then these should be given by any artificial means except to relieve obvious suffering
  • During such an illness, if my condition deteriorates without reversible cause, and as a result my behaviour becomes violent, noisy, or in other ways degrading, or if I appear to be suffering severe pain, then any such symptoms should be controlled with suitable drug treatment, regardless of the consequences on my physical health and my survival, within the extent of the law

The object of this directive is to minimise distress of dignity which I may suffer or create during an incurable illness, and to spare my medical advisors or relatives, or both, the burden of making difficult decisions on my behalf.

Statement of one witness

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