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Living Will

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Living Will: Ł15.00

Details marked * are compulsory, although you should try to complete as much as possible.

Section 1 - Personal Details

Surname:*

Forenames:*

Title:

Date of Birth:*

Address:*

Postcode:

Home Telephone:

E-mail:

Section 2 - My Wishes Are

I make this living will with full understanding of its consequences and am of sound mind. I wish the following instructions to be carried out if two independent medical practitioners are of the opinion that I am no longer capable to make and communicate a treatment decision, and furthermore, that I am unlikely to recover from the illness or impairment from which I am suffering.

If I am suffering from the following:*

	Unconscious and unlikely to ever regain consciousness
	Advanced disseminated malignant disease (eg. widespread lung cancer)
	Severe immune deficiency (AIDS)
	Advanced degenerative disease of the nervous system
	Severe and lasting brain damage due to injury, stroke, disease or other cause
	Senile or pre-senile dementia
	So severely mentally or physically incapable that I shall be dependent on others for the duration of my life

Then I wish not to be subjected to any medical intervention or treatment aimed at prolonging my life.

	Furthermore, I wish to be given any treatment which may reduce my pain and suffering even though this may shorten my life.
	Should euthanasia be legal at such time as this Living Will may be interpreted, I request that this would be my preferred choice.

Please state if you would like your living will to be taken into account for any other illness or injuries you may suffer from. Also please state any other wishes that you might have, regarding your care and treatment.

Section 3 - Please Consult (optional)

In the event of any severe illness or accident, I nominate:

Full Name:
Address:
Postcode:
Relationship:

Full Name:
Address:
Postcode:
Relationship:

to be consulted by my medical attendants when considering my wishes.

Section 4 - My Doctor is:

Full Name:*

Address:*

Postcode: