Advance Directive Form for Passive Euthanasia

Also read - Passive Euthanasia in India and Making Advance Medical Directives: Details that hospitals and patients must know

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ADVANCE MEDICAL DIRECTIVE
A. – ACKNOWLEDGEMENT BY PATIENT
I, __________________________________________ (name of patient giving directive), would like to make and communicate following wishes to those who will be responsible for my healthcare, who must follow the directions written on this form. I acknowledge that, ·         I am major by age and in a sound mind to issue these directives. ·         I can withdraw or modify these directives, in written, at any point of time henceforth ·         I have been explained and I fully understand the consequences of this advance directive
B. EXPLANATION OF TERMS
If I become terminally ill, I want that the life sustaining treatment must be _______________________________________ (continued / not continued) on me If I become terminally ill, I want that food and water provided through a tube or an IV should be ___________________________________________ (continued / not continued) If I become permanently un-conscious, I want that the life sustaining treatment must be _______________________________________ (continued / not continued) on me If I become permanently un-conscious, I want that food and water provided through a tube or an IV should be ___________________________________________ (continued / not continued) I know that even if I choose not to have life sustaining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable I understand that if I am terminally ill or injured I may need to be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me Any other directive: _______________________________________________________________ ________________________________________________________________________________
C. EXPLANATION OF TERMS
·                               Terminally ill – is when a qualified doctor or a team of doctor decide that I have a condition that cannot be cured and that I will likely die in the near future from this condition ·                               Life sustaining treatment – Life sustaining treatment includes drugs, machines, or medical procedures (including Cardio-pulmonary resuscitation) that would keep me alive but would not cure me. ·                               Permanent unconsciousness is when a qualified or a team of doctors agree that within a reasonable degree of medical certainty I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely without hope for improvement and have watched me long enough to make that decision
D. PERSON AUTHORIZED TO GIVE CONSENT ON MY BEHALF
I nominate following person whose consent should be taken before executing the above directives. The person can also make healthcare decisions, not specified here, on my behalf. I ascertain that these persons are of major age and in a decision making state First Choice Name: ____________________________________ Relationship with me: ______________________________ Address: _______________________________________ Second Choice (In case first choice person not available) Name: ____________________________________ Relationship with me: ______________________________ Address: _______________________________________
Instructions (if any) for the person consenting/making decision on patient’s behalf _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
E. Signatures
Name and signature of the person giving advance directive		Date / Time
Signature of person authorized for consent/decisions: I am willing to make decisions/consent on healthcare related matter on patient’s behalf
Name, signature and relationship of the person (First choice)		Date / Time
Name, signature and relationship (Second choice)		Date / Time
Signature of Witnesses: “I am satisfied that the document has been executed voluntarily and without any coercion or inducement or compulsion and with full understanding of all the relevant information and consequences”
Name and signature of Witness number 1		Date / Time
Name and signature of Witness number 2
Signature of Judicial Magistrate of First Class: “I am satisfied that the document has been executed voluntarily and without any coercion or inducement or compulsion and with full understanding of all the relevant information and consequences”
Name, signature and District of JMFC (With official stamp)		Date / Time

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