Full name.......................................................................
Full address....................................................................
................................................................................
Postcode....................... Date of Birth...................................
Your GP's name .................................................................
Your GP's address ..............................................................
................................................................................ GPs telephone number...........................................
I have discussed the contents of this form with my GP Yes/No (delete one)
I have discussed the contents with another health professional mentioned below Yes/No (delete one)
I have made this declaration at a time when I am of sound mind and after careful consideration. I understand that my life may be shortened by the refusals of treatment in this form. I accept the risk that I may not be able to change my mind in the future when I am no longer able to speak for myself, and I accept the risk that improving medical technology may offer increased hope, but I personally consider the risk of unwanted treatment to be a greater risk. I want it to be known that I fear degradation and indignity far more than death. I ask my medical attendants to bear this in mind when considering what my intentions would be in any uncertain situation. The decisions set out in my living will apply, even if my life is at risk as a result.
If the time comes when I can no longer communicate, this declaration shall be taken as a testament to my wishes regarding medical care. If it is the opinion of two independent doctors that there is no reasonable prospect of my recovery form severe physical illness, or from impairment expected to cause me severe distress or render me incapable of rational existence, then I direct that I be allowed to die and not be kept alive by artificial means such as life support systems, tube feeding, antibiotics, resuscitation or blood transfusions: any treatment which has no benefit other than a mere prolongation of my existence should be withheld or withdrawn, even if it means my life is shortened. I accept basic care however and I request aggressive palliative care, drugs or any other measures to keep me free of pain or distress, even if they shorten my life.
I have the following wishes about specific treatments or investigations:
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My other wishes/personal statement:.............................................
................................................................................
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I wish the following person to be consulted in the event of uncertainty about my wishes:
Name............................................................................
Address.........................................................................
Telephone.......................................................................
MY SIGNATURE....................................................................
DATE...........................
Witness (name)..................................................................
Signature of witness............................................................
Address of witness..............................................................
................................................................................
Reviewed: date:......................... My signature.....................
Reviewed: date:......................... My signature.....................
Living Will & Values History Project