Advance Decision to Refuse Treatment
  • Document Details
    • Who is patient?
    • Specified Treatment
    • Scope of Application
    • Miscellaneous
  • Complete the Document
    • Format & Signatures

Who is patient?

  • Indicate the full name of a person making this advance directive (Principal):

  • Select the principal's gender:

    !

    This is needed to understand further in questionnaire if the principal wishes to avoid any specific treatments during their pregnancy.

  • Indicate the full residential address of the Principal:

  • Indicate the Principal's date of birth:

  • Is the principal registered with NHS?

  • Indicate the principal's NHS number:

Specified Treatment

  • If the principal has a terminal medical condition, does the principal want to refuse food and water to be provided artificially through a tube?

  • If the principal has a terminal medical condition, does the principal want to refuse to heart resuscitation?

  • If the principal has a terminal medical condition, does the principal want to refuse to artificial respiration?

  • If the principal has a terminal medical condition, does the principal want to refuse to any other additional treatments not listed above?

  • List any other special treatments the principals wants to refuse to:

  • Does the principal want to apply this directive where any treatment or procedures are deemed necessary for the safe delivery and birth of my child?

Scope of Application

  • Shall this directive apply in a situation when the principal is in constant, unremitting pain?

  • Shall this directive apply when the principal has any physical illness from which there is no real possibility of recovery and from which it is likely that death will result?

  • Shall this directive apply when the principal has any serious impairment of the mind or brain with little or no prospect of recovery?

  • Shall this directive apply when the principal is unconsciousness or in coma from which the principal will unlikely ever be regained?

  • Shall this directive apply when the principal has a persistent negative state or minimal consciousness?

Miscellaneous

  • Indicate full name of the principal's general practitioner (GP):

  • Indicate registered business address of the GP:

  • Select the jurisdiction where the principal currently resides:

  • Do you want to add a signature?

  • Principal's signature:

Select a template's format:

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