A Living
Will
(The Natural Death Centre's Adaptation)
Introduction
The following Living Will has been
adapted by the Natural Death Centre from those put out by the
Voluntary Euthanasia Society, the Terrence Higgins Trust and
others. The British Medical Association approve of Living Wills.
You would be well advised however to discuss your Living Will with
your GP, or with another doctor if necessary and to lodge a copy
with a doctor (it might be best to change doctor if necessary, in
order to find one who is sympathetic to the Living Will concept)
and also give a copy to your relatives. If you go into
hospital, you can slow it to your doctors there and have a copy put
in your notes. You may also wish to update the form every few
years, even if just to sign and have witnessed the statement to the
effect that it still represents your wishes. Strike out any parts
which you do not wish to apply to your case or write your own
version entirely. If you appoint representatives these should be
people you trust absolutely, especially if they would benefit
financially from your death.
TO MY FAMILY, MY PHYSICIAN AND ALL OTHER PERSONS
CONCERNED. THIS DIRECTIVE is made by me at a time when I
am of sound mind and after careful consideration. I wish to be
fully informed about any illness I may have, about treatment
alternatives and likely outcomes.
I DECLARE that if at any time the following
circumstances exist namely:
- I suffer from one or more of the conditions mentioned in the
schedule below; and
- I have become unable to participate effectively in decisions
about my medical care; and
- Two independent physicians (one a consultant) are of the
opinion that I am unlikely to recover from illness or impairment
involving severe distress or incapacity for rational
existence.
THEN AND IN THOSE
CIRCUMSTANCES my directions are as follows:
- That I am not to be subjected to any medical intervention or
treatment aimed at prolonging or sustaining my life;
- That any distressing symptoms (including any caused by lack of
food) are to be fully controlled by appropriate analgesic or other
treatment, even though that treatment may shorten my life.
- That I am not to be force fed (although I wish to be given
water to drink);
- That I wish to be allowed to spend my last days at home if at
all possible.
I consent to anything proposed to be done or omitted in
compliance with the directions expressed about and absolve my
medical attendants from any civil liability arising out of such
acts or omission.
I wish to be as conscious as my circumstance permit (allowing
for adequate pain control) as death approaches. I ask my medical
attendants to bear this statement in mind when considering what my
intentions would be in any uncertain situation.
I RESERVE the right to revoke this
DIRECTIVE at any time, but unless I do so it
should be taken to represent my continuing directions.
THE SCHEDULE
- Advanced disseminated malignant disease
- Severe immune deficiency
- Advanced degenerative disease of the nervous system
- Severe and lasting brain damage due to injury, stroke, disease
or other cause
- Senile or pre-senile dementia, whether Alzheimer's
multi-infarct or other
- Any other condition or comparable gravity
I have lodged a copy of this Living Will with the following
doctor,
with whom I have/have not discussed its contents:
(Name)__________________________(Tel
No)_________________
(Address)_______________________________________________
Should I become unable to communicate my wishes as stated
about and should amplification be required, I appoint the following
person to represent these wishes on my behalf and I want this
person to be consulted by those caring for me and for this person's
representation of my views to be respected:
(Name)__________________________(Tel No)________________
(Address)______________________________________________
My Signature____________________ Date___________________
My Name______________________________________________
(Address)______________________________________________
WE TESTIFY that the above named signed this Directive in our
presence, and made it clear to us that he/she understood what it
meant. We do not know of any pressure being brought on him/her to
make such a directive and we believe it was made by his/her own
wish We are over 18, we are not relatives of the above named, nor
do we stand to gain from his/her death.
Witnessed by:
Signature________________________
Signature_______________________
Name___________________________
Name__________________________
Address_________________________
Address________________________
________________________________
_______________________________
FOR RENEWING WILL IN LATER YEARS
I reaffirm the contents of my Living Will above,
My Signature_______________________
Date___________________
Witness by:
Signature________________________
Signature_______________________
Name___________________________
Name__________________________
Address_________________________
Address________________________
________________________________
_______________________________