Create Your Future: Free Advance Decision Template for Healthcare Planning
This document is an Advance Decision, also known as a Living Will, where an individual states their wishes to refuse specific medical treatments under defined circumstances, such as a persistent vegetative state, terminal illness, or severe dementia. It ensures their healthcare preferences are respected if they lose the capacity to make decisions in the future.
ADVANCE DECISION
I, [name], born on [date of birth], residing at [address], being of sound mind, hereby make this Advance Decision to refuse medical treatment.
Statement of Intent
This document is my Advance Decision to refuse medical treatment. It represents my wishes and values and should be followed if I lack the capacity to make treatment decisions at any time in the future.
Declaration of Capacity
I confirm that I am at least 18 years old and I make this Advance Decision voluntarily, without any undue influence, and I understand the nature and consequences of refusing medical treatment.
Specific Refusals of Treatment
I refuse the following treatments under the circumstances described below:
[a] If I am in a persistent vegetative state or in a condition of irreversible unconsciousness, I refuse:
Life-sustaining treatments including mechanical ventilation, resuscitation, and artificial nutrition and hydration.
[b] If I have a terminal illness where death is imminent, I refuse:
Treatments that may prolong life but do not provide comfort or relieve pain, including blood transfusions, dialysis, and use of breathing machines.
[c] In the event of severe dementia or irreversible cognitive impairment, I refuse:
Antibiotics for life-threatening infections and other treatments that may prolong life but do not improve quality of life.
Power of Attorney
If I have appointed a Health Care Power of Attorney [or similar], their authority is to interpret and enforce this Advance Decision.
Validity and Revocation
This Advance Decision will remain effective indefinitely unless I revoke it in a written document.
Legal Protection for Health Care Providers
I understand that no healthcare provider who respects my wishes as set out in this Advance Decision will be liable for my death.
Signatures
Signed by [name]
Date:
Signature
Witness Declaration I declare that the person signing this Advance Decision:
[a] Is personally known to me and appears to be of sound mind and not under duress, fraud, or undue influence. [b] Has signed this Advance Decision in my presence.
Witness Name:
Address:
Date:
___________________________
Witness Signature
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