T E A m o r t a l i www.mortalitea.me Your GP to keep with your records Someone who you wish to be consulted about your treatment should this ever be necessary (e.g. next of kin, power of attorney etc) A member of the Palliative Care Team, Hospital Consultancy Team, Hospice Team, District Nurse, Care Home Manager as appropriate An Advanced Decision (AD) is different from an ACP which reflects your wishes and preferences. An AD is a formal, legally binding document which allows an individual to refuse certain treatments. A person must be over the age of eighteen to make an AD and must have the mental capacity to do so. Please note: Advanced Decisions are legally binding in England, Wales & Northern Ireland. They are NOT legally binding in Scotland but should be considered by doctors. An AD is very specific and is used in situations where certain treatments are not acceptable to the patient. For example, if a person had a medical condition which resulted in them having problems swallowing, they would not wish to be fed by an alternative method. Before making an AD it might be helpful to seek advice from someone who understands the process such as a local advice service, a member of your healthcare professional team, or if your circumstances are particularly complex, a solicitor. An AD can be made verbally, e.g. in a conversation with your GP, but if it includes any refusal of treatment, it must be in writing and must be signed and witnessed; it must also specifically include the statement ‘even if life is at risk’. An AD will only be used if, at some point in the future, you lose the ability to indicate your decision at the point of need about your medical treatment. To be valid your AD must be made before you lose the ability to make such decisions. You can change your mind about your AD and amend it at any time, provided to still have the mental capacity to do so. Please Note: An Advanced Decision does NOT allow for a request to have life ended and cannot be used to request medical treatment. All forms of assisted suicide, including what is commonly referred to a physician assisted suicide, are currently ILLEGAL in the United Kingdom, and doctors found to be assisting a suicide can be jailed for up to 14 years, under the Suicide Act 1961. It may be helpful to provide copies of this form to professionals who are involved in your care such as: An AD needs to be signed and witnessed by another person who is not a close relative or someone who is expecting to benefit from your Will. ADVANCED DECISION It is your responsibility to make sure that healthcare professionals and other relevant people are aware that your Advanced Decision exists. If they do not know about it, they cannot act in accordance with it. INFORMATION - PLEASE READ THIS BEFORE COMPLETING THE FORM To my doctor and other persons concerned in my healthcare, this Advanced Decision is made by me: Name Date of Birth Address I am writing this at a time when I am able to think things through clearly and I have carefully thought about my situation. I am aware that I have been diagnosed with: I have understood the likely prognosis of this and am making an informed decision regarding my future care. OR I am writing this at a time when I am able to think things through clearly and I have carefully thought about my future care plans. I have not been diagnosed with anything but wish it to be known in the case of a severe accident or incapacity where artificial life-sustaining treatment may be considered by medical professionals but with no potential positive outcome. I have understood the implications of this and am making an informed decision regarding my future care. I am over 18 years old. I am writing this of my own free will. I declare that if I become incapable of making decisions about my medical care, then and in those circumstances, my directions are as follows (only sign the sections you feel are applicable to you) I do not want to receive any medical interventions or treatment aimed at artificially prolonging my life, even where my life is at risk. I confirm that the following refusal(s) of treatment are to apply even if my life is at risk or may be shortened as a result. ADVANCED DECISION T E A m o r t a l i www.mortalitea.me My details Declaration I have been diagnosed with any of the conditions I have included in (A) to (D) below, and I can no longer make or communicate decisions about my medical treatment, and I am unlikely to regain the ability to make these decisions. I refuse all life-sustaining treatment if: I understand life-sustaining treatment includes but is not limited to Cardio-pulmonary Resuscitation (CPR), clinically assisted nutrition and hydration, artificial or mechanical ventilation and antibiotics for life-threatening infections. My Advanced Decision includes any of the following: Any type of dementia Brain injury I understand that brain injury includes but is not limited to stroke, vegetative and minimally conscious states. Diseases of the central nervous system I understand that a disease of the central nervous system includes but is not limited to motor neurone disease, Parkinson’s Disease and Huntington’s Disease. Terminal illness Refusing treatment in other situation (Continue on another sheet if necessary) ADVANCED DECISION T E A m o r t a l i www.mortalitea.me Tick the boxes to which you wish to apply your refusal. You may add any other situations here that you wish to include in your advanced decision For the avoidance of doubt Pain relief: I wish to be given all medical treatment intended to alleviate pain or distress, or aimed at ensuring my comfort. Pregnancy: If I am pregnant, I wish to receive any medical treatment or procedures necessary leading to the safe delivery of my child. Once my child is safely delivered, I wish to reinstate my wishes as set out in this form. Organ donation: I am on the Organ Donor Register I reserve the right to revoke this Advanced Decision at any time, but unless I do so it should be taken to represent my continuing directions, even where my life is at risk I have spoken with my GP/Healthcare Provider about my AD I have not spoke with my GP/Healthcare Provider about my AD Dr. : Surgery: Address: Telephone: Other Healthcare Provider details: e.g. Hospice, Consultant, District Nurse etc Name: Healthcare Role: Address: Telephone: It is recommended that you discuss this with at least one of the above professionals. If you are in hospital or hospice then the consultant caring for you should be aware of and clear about the scope of your AD. ADVANCED DECISION T E A m o r t a l i www.mortalitea.me Whether you have spoken to your GP or not, include their details here If you are under the care of another healthcare Provider, include their details here Signed Date Advanced Decision Completed: Witness(es): Only one witness is legally required, but you may have a second witness if you wish. I/We testify that the maker of this Advanced Decision signed it in my/our presence, and made it clear that he/she/they understood what it meant. I/We do not know of any pressure being brought on him/her/them to make such a Decision and I/we believe it was made by his/her/their own wish. I/we do not stand to gain from his/her/their death. Witness 1 Name: Date: Signature: Address: Witness 2 Name: Date: Signature: Address: Reviews of my Advanced Decision: The Advanced Decision was reviewed and confirmed by me on: Date Signed Witness Date Signed Witness Date Signed Witness Date Signed Witness ADVANCED DECISION T E A m o r t a l i www.mortalitea.me Witness 1: (recommended GP or other Healthcare Professional) There are no specific recommendations for how regularly you should review your AD. Your own circumstances will likely determine how often you will need to do this. Signature Witness(es) Witness 2: (not close family, or beneficiary of your Will) Reviews