APPENDIX 3
EXAMPLES OF LIVING WILLS—B
LIVING WILL ALLOWING FOR REFUSAL OF UNWANTED
TREATMENT
TO MY FAMILY, MY PHYSICIAN AND MY SOLICITOR
This declaration is made by me, residing
at
at a time when I am of sound mind and after
careful consideration.
I, the said
in the event of my being unable to take part
in decisions concerning my medical care due to my physical or
mental incapacity, and in the event that I develop one or more
of the medical conditions listed in clause (3) below and in the
event that two independent physicians conclude that there is no
reasonable prospect of my making a substantial recovery, do hereby
DECLARE that my wishes are as follows, viz:—
(1) I request that my life should not be
sustained by artificial means such as life support systems, intravenous
fluids and/or drugs or tube feeding.
(2) I request that distressing symptoms
caused either by illness or by lack of food or fluid should be
controlled by appropriate sedative treatment, even though such
treatment may have the incidental and secondary effect of shortening
my life.
(3) The said medical conditions are:—
1. Severe and lasting brain damage
sustained as a result of an accident or injury.
2. Advanced disseminated malignant
disease.
3. Advanced degenerative disease
of the nervous and/or muscular systems with severe limitations
of independent mobility, and no satisfactory response to treatment.
4. Stroke with extensive persisting
paralysis.
5. Pre-senile, senile or Alzheimer
type dementia.
6. Other conditions of comparable
gravity.
(4) I request that, in the event of my becoming
incapable of giving or withholding consent to any medical treatment
or procedures proposed to me, the Court be petitioned to appoint
as my Welfare Guardian,
residing at
whom failing
residing at
whom again failing
whom all failing
such other person as may be deemed
by the Court to be a fit person. It is my specific request that
in exercising his or her powers to consent or withhold consent
on my behalf to any medical treatment or procedures, my guardian
shall take into account, in any determination of what is in my
best interests, the requests which I solemnly make in clauses
(1) and (2) of this document.
And I declare that I hereby absolve my medical
attendants of all legal liability arising from action taken in
response to and in terms of this declaration.
I reserve the right to revoke this declaration
at any time, before a witness, in writing or orally.
SIGNED by me at
on the
day of
Two thousand
in the presence of:—
Witness
Full Name
Address
(In Scotland only one witness is required)
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