Page 280 - Demo

INSTRUCTIONS IF I AM SO SEVERELY DISABLED, PHYSICALLY OR MENTALLY, THAT I WILL NEED [INTENSIVE] MEDICAL TREATMENT TO KEEP ME ALIVE, OR WILL BE TOTALLY DEPENDANT ON OTHERS, FOR THE REST OF MY LIFE
Delete one of the following statements –
[I wish to be kept alive for as long as reasonably possible. Please use any relevant medical treatments to achieve this.] OR
[I do not wish to be kept alive by medical treatment. Please only give me medical treatments which will so far as possible keep me in dignity, in comfort and free from pain. I refuse all other medical treatment.]
BOX FIVE – SPECIFIC CONDITIONS OR TREATMENTS
Put in the rst column below the condition(s) from which you suffer, and put in the second column any particular medical treatments or tests which you may wish to have or which you may wish to refuse.
Please note that you do not have the legal right to demand that you receive particular treatment, but your wishes can be taken into account.
INTRODUCTION
I would like these instructions to be acted upon if [two registered medical practitioners are of the reasonable opinion that] I am no longer capable of making and communicating a decision regarding my treatment.
CONDITION
I suffer from the following illness or condition:
INSTRUCTIONS
These are my instructions regarding my treatment:
276 Appendix E