APPENDIX 6: NVVE EUTHANASIA STATEMENT
EUTHANASIA STATEMENT
NAME
DATE OF BIRTH PLACE OF BIRTH
MEMBERSHIP NUMBER
By this directive I address myself to the physician
treating me.
1 BASIC CRITERION
After thorough consideration I do not wish to live
further if I should come to be in:
a a condition of unbearable suffering, and/or
b a condition which provides little or no prospect
of a return to what is for me a reasonable and dignified existence
By the latter condition I mean in any event:
- a coma lasting longer than
<..> weeks;
- a permanent vegetative state (living mindlessly);
2 REQUEST FOR HELP IN ORDER TO BE ABLE TO
DIE
If I am in a condition as referred to in point 1
(a) or (b), I urgently request the physician treating me to
fulfil my death wish by allowing me to take substances under
his or her supervision—or, if I am no longer able to do
so, to administer to me substances—that will bring about
a mild death.
3 REFERRAL
If the physician treating me in the circumstances
referred to at 1 is unwilling or unable to comply with my above-mentioned
request, I request him or her to refer me immediately to another
physician who is willing and able to do so.
4 DUTY OF SECRECY
If my request has been complied with, an investigation
into my death will be instituted by the authorities. I release
the physician treating me from his or her duty of secrecy regarding
my medical particulars. I request him or her to provide the particulars
needed for that investigation.
5 RISK OF ACCEPTANCE
This directive will remain in force irrespective
of the period that has elapsed since its signature. I therefore
consciously accept the risk that I may later wish to amend or
revoke it, but am then no longer able to do so. I do this in order
to exclude a greater risk, namely that I should have to continue
living in circumstances that are not acceptable to me.
6 DEPOSIT
I will deposit a copy of this directive with my
family doctor or any other physician treating me and with my representative
(or deputy representative).
7 REPLACEMENT
I hereby replace my previous euthanasia statements.
The oldest of them was signed on <…………….>.
8 SIGNATURE
I have given careful thought to this directive and
to the additions signed to me. I am very clear about my wishes
on medical matters. To use the terms of the law, I am "able
to make an informed decision about my interests in this respect".
PLACE DATE SIGNATURE
9 ADDITIONS
In so far as they are ticked and signed,
I understand the following to be included in the situations referred
to in point 1:
a: a life with serious, permanent paralysis.
DATE SIGNATURE
b: being totally dependant on other persons for
such general daily activities as eating, drinking, going to the
lavatory, dressing and undressing.
DATE SIGNATURE
c: having a handicap such as being blind or virtually
blind and/or deaf and/or virtually deaf which make it impossible
or virtually impossible for me to perform what are for me worthwhile
activities such as reading, writing, watching television, listening
to music, and doing manual work or handicrafts.
DATE SIGNATURE
d: having a severe impairment or continuing
degeneration of my mental faculties, as a result of which I, for
example,
- no longer know who I am or where I am,
- have lost my capacity to communicate;
- no longer recognise those dear to me;
- must be confined because I would otherwise
go wandering.
DATE SIGNATURE
10 PERSONAL ADDITION (only if ticked and
signed)
Owing to my personal circumstances I have written
an addition to this directive. The addition is attached to this
directive and forms part of it.
DATE SIGNATURE
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