Fillable Printable Free Living Will Forms

Free Living Will Forms

Important:

Living Will

This document should be lodged with the declarant’s medical records.

A doctor having conscientious objection should immediately refer the declarant to another

doctor. Living wills are accepted in the British Medical Association’s ethical recommendations

and by common law. The form does not ask the doctor to do anything illegal.

Duplicate copies may optionally be lodged with a solicitor and a close friend, and a further copy

kept for reference.

Section A. ADVANCE MEDICAL DIRECTIVE. Note: This section may be legally binding.

Section A comprises specific instructions to the health-care team in the event that I can no longer

express my own wishes; it covers very serious conditions.

To the Declarant: When filling out this part of the form, you should cross out anything that does

not express your true wishes, then initial any changes clearly.

Section B. LIFE VALUES STATEMENT.

This gives indications of the personal value I attach to my life under various circumstances. I ask

my health care team to bear these in mind when making difficult decisions about my treatment or

non-treatment, especially in situations not covered by Section A. Where I have indicated that life

under such circumstances would be “Much Worse Than Death” this means that I would find the

situation totally unbearable and unacceptable, and that I would prefer all life-sustaining treatment

to be stopped or withdrawn rather than exist for the rest of my life in such a state.

Note: A doctor should not be liable to civil or criminal proceedings if he acts in good faith and

with reasonable care in respecting the directives and values in this document.

DO NOT FILL OUT THIS FORM WITHOUT DEEP AND CAREFUL CONSIDERATION.

Complete Section A or Section B or both.

For further information and advice on living wills, you may wish to consult your doctor or one

of the organisations or individuals listed below:

Age Concern England, Astral House, 1268 London Rd, London SW16 4ER;

Phyllis Goodheir, 16 Woodlands Drive, Coatbridge, ML5 1LE;

The Natural Death Centre, 20 Heber Rd, London NW2;

The Terrence Higgins Trust, 52-54 Gray’s Inn Rd, London WC1X 8JU;

The Voluntary Euthanasia Society, 13 Prince of Wales Terrace, London W8 5PG;

The Voluntary Euthanasia Society of Scotland, 17 Hart St, Edinburgh EH1 3RN.

Solicitors in England may wish to contact The Law Society, Law Society House, 50/52 Chancery Lane,

London WC2A.

Physicians maywishtocontactThe British Medical Association, Ethics Department, BMA House, Tavistock

Square, London WC1H 9JP, and consult their code of practice, “Advance Statements about Medical Treatment”.

suggestions for further development which should be addressed to CG Docker, BM 718, London WC1N 3XX U.K. Much of the text is drawn from

existing documents, and many individuals and organisations have contributed ideas and made helpful suggestions, including the National Agency for

Welfare and Health Helsinki and the Ethics Committee of the Seattle Veterans Affairs Medical Center.

Personal copies may be made by the Declarant for his or her own use.

O Insert in Patient’s Medical Records O

SECTION A. ADVANCE MEDICALDIRECTIVE

TO MY PHYSICIAN AND HEALTH CARE TEAM, MY FAMILY, MY SOLICITOR

AND ALL OTHER PERSONS CONCERNED:

this declaration is made at a time when I am of sound mind and after

careful consideration.

I UNDERSTAND THAT MY LIFE MAY BE SHORTENED BY THE SPECIFIC

REFUSALS OF TREATMENT MADE IN THIS DOCUMENT.

I DECLARE that if at any time the following circumstances exist, namely:

(1) I suffer from one or more of the conditions mentioned in the Schedule; and

(2) I

have become unable to participate effectively in decisions about my medical care; and

(3) two independent physicians (one a consultant) are of the expert, considered opinion, after

full examination of my case, that I am unlikely to make a substantial recovery from illness or

impairment involving severe distress or incapacity for rational existence,

THEN AND IN THOSE CIRCUMSTANCES my directions are as follows:

1. that I am not to be subjected to any medical intervention or treatment (aimed at prolonging

my life) such as life support systems, artificial ventilation, antibiotics (i.e. to control infection),

artificial feeding - whether enteral or parenteral (tube feeding into the stomach or into a vein),

invasive surgery, dialysis (e.g. using a kidney machine), or blood transfusion;

2. that any distressing symptoms (including any caused by lack of food or fluid) are to be

fully and aggressively controlled by appropriate palliative care, ordinary nursing care,

analgesic or other treatments, even though some of these treatments may have the secondary

effect of shortening my life.

HOWEVER, modes of treatment mentioned in (1) above may be applied for elimination of

serious symptoms. Giving intensive care to me is to be allowed only on the condition that

reliable reasons exist for the possibility that such treatment will have a better result than merely

short prolongation of life. In the event that a treatment with prospect of recovery has been

started but proves to be futile, it has to be discontinued immediately.

I consent to anything proposed to be done or omitted in compliance with the directions

expressed above and absolve my medical attendants from any civil liability arising out of such

acts or omissions.

I offer the health-care team my heartfelt thanks for respecting my sincerely held wishes, as

expressed in this directive.

I accept the risk that I may be unable to express a change of mind at a time in the future when I

am incapacitated, that improving medical technology may offer increased hope, but I

personally consider the risk of unwanted treatment to be a greater risk. I wish it to be

understood that I fear degradation and indignity far more than death. 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, orally or in writing,

but unless I do so it should be taken to represent my continuing directions. I hereby deliberately

accept the risk that I may no longer be able to revoke my declaration if I am in a condition

listed in the Schedule, in order to exclude a risk which is greater to me, namely that I should

continue living in circumstances that are not acceptable to me.

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Section A continued

SCHEDULE

A Advanced disseminated malignant disease (e.g. cancer that has spread considerably)

B Severe immune deficiency (e.g. Acquired Immune Deficiency Syndrome)

C Advanced degenerative disease of the nervous system (e.g advanced Parkinson’s Disease)

D Severe and lasting brain damage due to injury, stroke, disease or other cause

E Advanced dementia, whether Alzheimer’s, multi-infarct or other, resulting in very limited

awareness of the immediate environment and inability to initiate simple tasks

F Any other condition of comparable gravity

Additional instructions (if any, such as pregnancy waiver) . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

If you would like a particular person’s wishes to be taken into consideration during decisions

about your medical care, please give their details here:

Name of my proxy . . . . . . . . . . . . . . . . . . . . Telephone number . . . . . . .

Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

To my proxy: Please try to ensure that decisions are taken

(mark one box only) how you believe I would have taken them

using your own best judgement

The wishes of your proxy may be taken into consideration, but have no overriding force in British law -

neither do the wishes of relatives. It is advisable to discuss this document with your proxy.

I have discussed this document with my doctor Mark here if Yes

Doctor’s Tel. No . . . . . . . . . . . . . Name of Doctor . . . . . . . . . . . . . . . . .

Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

It is not obligatory to discuss your living will in advance with your doctor, but it may be

very helpful to do so.

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(a) Permanently paralysed. You are

unable to walk but can move around in a

wheelchair. You can talk and interact with

other people.

(b) Permanently unable to speak

meaningfully. You are unable to speak to

others. You can walk on your own, feed

yourself and take care of daily needs

such as bathing and dressing yourself.

yourself. You are bedridden, unable to

wash, feed, or dress yourself. You are

totally cared for by others.

(d) Permanently in pain. You are in severe

bodily pain that cannot be totally controlled

or completely eliminated by medications.

(e) Permanently mildly demented. You

often cannot remember things, such as

where you are, nor reason clearly. You

are capable of speaking, but not capable

of remembering the conversations; you

are capable of washing, feeding and

dressing yourself and are in no pain.

(f) Being in a short term coma. You have

suffered brain damage and are not

conscious and are not aware of your

environment in any way. You cannot feel

pain. You are cared for by others. These

mental impairments may be reversed in

about one week leaving mild forgetfulness

and loss of memory as a consequence.

Much

Worse Than

Death: I

Would

Definitely

Not Want

Life

Sustaining

Treatment

Somewhat

Worse Than

Death: I

Would

Probably

Not Want

Life

Sustaining

Treatment

Neither

Better Nor

Worse Than

Death: I’m

Not Sure

Whether I

Want Life-

Sustaining

Treatment

Somewhat

Better Than

Death: I

Would

Probably

Want Life-

Sustaining

Treatment

Much Better

Than Death:

I Would

Definitely

Want Life-

Sustaining

Treatment

SIGNATURE OF DECLARANT to Sections A & B: . . . . . . . . . . . . . . . . . . . .

Name (print clearly) . . . . . . . . . . . . . . . . . . Day/Month/Year . . . . . . . .

Address. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date of Birth* . . . . . . . . . .

*If you are under 18 years of age, you may still complete this document, though it may not have the same legal force.

WITNESS’S SIGNATURE: I declare that the abovenamed has signed this document in my presence. He/she has declared it to be

his/her firm will, is in full capacity and fully understands the meaning of it. I believe it to be a firm and competent statement of

his/her wishes. As far as I am aware, no pressure has been brought to bear on him/her to sign such a document and I believe it to

be his/her own free and considered wish. So far as I am aware, I do not stand to gain from his/her death.

Signed (Witness): . . . . . . . . . . . . . . . . . . . . Name . . . . . . . . . . . . . .

Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Circle the number on the scale

of one to five, that most closely

indicates your feelings about

each of the situations

described.

SECTION B. VALUES HISTORY STATEMENT

Please use this section as a

guide to my values when considering the likely result of treatment.

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