Advance Directive for Health Care
This document is directed to any medical practitioner who in the future may be responsible for my
medical care, to my legally appointed Enduring Power of Attorney for Personal Care and Welfare, or my
Court Appointed Welfare Guardian, and to my family members.
I have written in this directive my wishes for future health care. I understand that it will only be used when
I am unable to make decisions for myself. If any of the following situations arise, it is my wish that the
guidelines I ticked below are followed:
• If I have severe or permanent brain damage or
• If I have a terminal condition caused by injury or illness for which there is no cure AND
• If life sustaining treatment will only prolong the dying process
The primary goal is to relieve any symptoms of pain and/or distress I have and not to prolong my life.
In the event of my heart stopping, regardless of the cause, do not attempt to restart. Allow natural
death.
The object of this directive is to ensure that my wishes are made clear to all medical staff responsible for
my care. I would like to avoid anyone, especially my family, having to make difficult decisions on my behalf.
Finally I wish to state that by completing this document it is my intention to authorise effective symptom
relief for myself in the circumstances described.
I ________________________________________ have discussed the circumstances listed in this Advance
Directive and the guidelines about care and treatment with Dr__________________________________
[GP or specialist] who has explained the consequences of the Directive to me. I believe I have now had
sufficient time to understand and consider that information and sign this document.
I intend this Advance Directive to apply EITHER indefinitely /OR for the next [ ] years.
[NB: if specifying the
number of years, delete “indefinitely” and complete the number of years you intend the directive to apply for.]
Signed ________________________________________________ Date: ___________________________
Witness 1
Name: ________________________________________________________________________________
Signature: __________________________________________________ Date: _____________________
Witness 2 and witness statement (to be completed by doctor)
I declare that in my opinion the above person is mentally competent, understands the meaning and
implications of this directive, and has completed this directive entirely voluntarily.
Name: __________________________________
Designation: ______________________________
Facility / organisation: ____________________________________________________________________
Signature :______________________________________________ Date ___________________________
If I become unable to swallow food, fluid, or my regular medications, do not give these by any
artificial means.
Other
Name:
Address:
NHI:
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