Advance Decision Pack - Compassion in Dying · Advance Decision Pack Your download document contains: ☐ Advance Decision Form Legal document to register your treatment wishes (PDF

Advance Decision PackYour download document contains:

☐ Advance Decision FormLegal document to register your treatment wishes(PDF pages 2-9; Advance Decision pages 1-8)

☐ Guidance NotesStep-by-step guidance and advice on filling out your Advance Decision form(PDF pages 10-19; Guidance Notes pages 1-10)

☐ Notice of Advance Decision Card(PDF page 20)

You can fill out your Advance Decision form electronically, bytyping, and then print it off and sign it, or you can print the formoff first and fill it in by hand. If you fill it out electronically, you andyour witnesses must still sign it by hand.

Advance Decision cover sheet

This is an Advance Decision to Refuse Treatment (ADRT). Although the legal term is ‘Advance Decision toRefuse Treatment’ it is commonly shortened to ‘Advance Decision’, and that is the term used throughoutthis form. It used to be called a Living Will and is also sometimes called an Advance Directive.

The Mental Capacity Act 2005 provides the legal framework for Advance Decisions.

An Advance Decision allows you to set out the treatment or procedures you wish to refuse, shouldyou lose the capacity to make decisions for yourself in the future. This form also includes an AdvanceStatement (section 4), which is a general statement about anything that is important to you inrelation to your future treatment and wellbeing. A healthcare professional is legally bound to followa valid and applicable Advance Decision. An Advance Statement is not legally binding in the sameway, however a healthcare professional must consider the wishes you express in your AdvanceStatement when making any decision on your behalf.

We strongly advise that you discuss your decisions with your GP and those closest to you so that theyare fully aware of your wishes. The accompanying Guidance Notes will help you to fill in this form.

Note to Healthcare Professionals:This document should be used in the event of loss of capacity of the individual identified below.

To treat the person named below contrary to the clearly expressed Advance Decision toRefuse Treatment (sections 1 and 3) is likely to be civil trespass and/or a criminal assault.

I (name)

of (address)

have the capacity to make the decisions set out in this document. I have carefully considered how Iwish to be treated if, in the future, I lose the capacity to make or communicate decisions about mymedical treatment. I have indicated in Sections 1 and 3 by ticking the box next to the relevantstatement, and/or writing in my own words, the medical treatment that I do not consent to.

Date of birth National Health Service (NHS) No.

Distinguishing features

(in the event of unconsciousness):

Review datesYou should, if possible, review and reaffirm your Advance Decision on a regular basis. You can sign anddate below to confirm that what you have requested in your Advance Decision continues to be yourwill. If you are unable to sign please ask someone to sign on your behalf.

I have reviewed my Advance Decision and reaffirm that the wishes stated in this document are my own.

Signed _____________________ Dated __________ Signed _____________________ Dated __________



Advance Decision page 1

Advance Decision to Refuse Treatment

REFUSAL OF TREATMENT

To avoid any doubt, and unless stated to the contrary below, I confirm that the followingrefusal(s) of treatment are to apply even if my life is at risk or may be shortened as a result.

1. Refusal of treatment

Medical treatment I DO NOT CONSENT TO (see Guidance Notes Section 1).

I refuse ALL medical treatment or procedures/interventions aimed at prolonging orartificially sustaining my life in the event that any or all of the following occur:

(A) I have an imminently life-threatening physical illness or condition from which there islittle or no prospect of recovery (in the opinion of two appropriately qualified doctors);

(B) I suffer serious impairment of the mind or brain with little or no prospect of recoverytogether with a physical need for life-sustaining treatment/interventions (in theopinion of two appropriately qualified doctors);

(C) I am persistently unconscious and have been so for at least _____ weeks and there islittle or no prospect of recovery (in the opinion of two appropriately qualified doctors).

(D) I have been diagnosed as being in a persistent vegetative state or minimally consciousstate and have been so for at least ___ weeks and there is little or no prospect ofrecovery (in the opinion of two appropriately qualified doctors).

You may choose statement E instead of, or in addition to, any of options A to D. See Guidancenotes, Section 1 (E).

(E) I wish to refuse medical treatments intended to prolong my life if I am in any of thefollowing situations:

(If necessary you may include a covering letter to expand on this Section).Covering letter attached.

I understand that my comfort and personal hygiene will continue to be attended to.


2. I wish it to be known

(A) I wish to be given any medical treatment intended to alleviate pain or distress, or aimedat my comfort. I maintain this request even in the event that it may shorten my life.

(B) If I am suffering from any of the conditions in Section 1 and I am pregnant, I wish toreceive medical treatment or procedures leading to the safe delivery of my child. Oncemy child is safely delivered I wish to reinstate my wishes as set out in the rest of thisdocument.


3. In respect of a known illness (see Guidance Notes Section 3 for further information).

I have been diagnosed with

I have the following wishes about specific treatment or investigations:

I refuse the following treatments for my condition:


I maintain this refusal of treatment even if my life is at risk or may be shortened as a result.


4. Advance Statement

This space gives you an opportunity to express your values, beliefs and any additional directionsyou have for your healthcare team. Stating your values and beliefs will help those treating you tobetter understand your wishes. It will help them to determine how you would want to be treated ifyou lacked capacity and a situation arose that wasn’t specified in your refusal(s) of treatment. Itcould also help healthcare professionals to understand what you consider to be an acceptablequality of life or recovery (for example, in relation to the statements made in section 1). Thedirections you write on this page are not legally binding, however anyone making a decision onyour behalf is required by law to consider these statements when deciding what is in your bestinterests.

(See Section 4 of the Guidance Notes for guidance on what you may wish to include).




5. Lasting Power of AttorneySee Section 5 of the Guidance Notes. Only complete this Section if you have already appointed a LastingPower of Attorney through the Office of the Public Guardian.

The details of my Lasting Power of Attorney are as follows:

Name

Address

Phone

Name

Address

Phone

6. GP details and (optional) declaration

My GP is

GP’s address

GP’s phonenumber

GP’s declaration: (optional – see Section 6 of the Guidance Notes)You don’t need your GP’s consent to make an Advance Decision but we recommend that you discussyour wishes with them and ask them to witness your mental capacity by signing this declaration. Youcould also discuss your Advance Decision with your nurse or hospital doctor and ask them to witnessthis document.

I have discussed the matters contained in this document with

(insert name)

I am satisfied that this individual has the capacity to make the decisions in this document and thatthey understand the consequences of these decisions.

Name ___________________________________

Signature ___________________________________ Date _______________________________


Copies of this Advance Decision

I have deposited other copies of this Advance Decision with: (e.g. your GP, family members).

1. Name 2. Name

Relationship Relationship

Address Address

Telephone Telephone

3. Name Relationship

Address

Telephone

7. WitnessesFor information on who can witness your Advance Decision see Section 7 of the Guidance Notes.

Witness 1 Witness 2 (optional)

Relationship Relationship

Address Address

I witness that this Advance Decision was I witness that this Advance Decision was signed or acknowledged in my presence signed or acknowledged in my presence

Signature _______________________________ ___ Signature _______________________________ __

Dated ________________ Dated ________________

DECLARATION AND SIGNATURE

Everything contained in this Advance Decision is true and correct at the time of writing.

Name

Signed __________________________________ Dated ______________

Compassion in Dying181 Oxford Street London W1D 2JT

Tel: 0800 999 2434 (10am to 4pm, Monday to Friday) Fax: 020 7287 1760Email: [email protected]

www.compassionindying.org.uk

Copyright © Compassion in Dying

Registered Charity in England and Wales, number 1120203

Date published: August 2014

Advance Decision to Refuse TreatmentGuidance Notes

IntroductionThese Guidance Notes are to help you to complete your Advance Decision to RefuseTreatment Form. You do not need to give them to your doctor.

What is an Advance Decision to Refuse Treatment?An Advance Decision to Refuse Treatment (ADRT) is commonly shortened to ‘Advance Decision’, and that is the termused throughout these Guidance Notes. It used to be called a Living Will and is also sometimes called an AdvanceDirective. It is legally binding in England and Wales, and should be binding under court law in Scotland and NorthernIreland. For information on Scotland and Northern Ireland please phone Compassion in Dying on 0800 999 2434.

What can it do?An Advance Decision allows you to make a legally binding refusal of treatment if you lose capacity – capacity is theability to make a decision. This means that, so long as your Advance Decision is valid and applicable (see below), ifyou lose capacity, a doctor cannot lawfully give you treatment that you have refused in your Advance Decision. Ifthey do, they could be prosecuted.

What can it not do?You cannot use your Advance Decision to ask for your life to be ended or to nominate someone else to decide abouttreatment on your behalf. Nominating another person to make decisions on your behalf is called making a LastingPower of Attorney (LPA). For more information on LPAs contact Compassion in Dying on 0800 999 2434.

You cannot use your Advance Decision to request or demand particular treatments. This is because, under the law inEngland and Wales, doctors do not have to give you a treatment just because you ask for it. Doctors decide whethertreatment is appropriate for your condition and you then decide whether or not you want that treatment.

How do I make my Advance Decision valid?For your Advance Decision to be valid you must:

• be 18 or over, and have the capacity to make your Advance Decision;

• not have been forced by others to make your decision;

• state the treatment(s) you wish to refuse (this can be in everyday, non-medical language);

• say the circumstances in which you want to refuse treatment;

• if you want to refuse life-saving treatment, clearly state that your Advance Decision applies if your life is atrisk as a result of refusing treatment (the Advance Decision form includes this wording and a checkbox atthe top of page 2 and at the bottom of page 4);

• have signed and dated your Advance Decision (in the presence of at least one witness – see page 8 of theseGuidance Notes);

• If you want to change any part of your Advance Decision, you must put your signature and the date next toany changes you make. You must either have sent a photocopy of these changes to everyone who holds acopy of your Advance Decision or have made these changes on each copy of your Advance Decision.

You do not need a solicitor to make an Advance Decision valid.

When is my Advance Decision applicable? Your Advance Decision is applicable if: you lose mental capacity; and it covers the circumstances you are in and thetreatments available to you; and there are no reasonable grounds to believe that changes in circumstance since youmade your Advance Decision would have changed the decisions you made in it.

What is mental capacity?Mental capacity is the ability of a person to make decisions for themselves about a particular matter. If you are an adultwith mental capacity you have the legal right to refuse any medical treatment. The law assumes that individuals have thecapacity to make decisions unless it is proven otherwise. For most decisions having ‘capacity’ means having the ability tounderstand and retain information relating to the decision, and taking that information into account when making yourchoice. For decisions about your health care and treatment, a doctor or other healthcare professional will need to decidewhether you have the capacity to make that decision.

Guidance Notes page 2

Whether or not you have capacity is decided on a decision-by-decision basis. For example, you might have capacity todecide whether you wanted to be cared for in hospital or at home, but not have capacity to decide whether you want torefuse life-saving treatment. You might lose capacity to make a decision for a short time (for instance, if you are knockedunconscious) or for the indefinite future (for instance, if you were in a persistent vegetative state).

Reviewing your Advance DecisionWe strongly advise you to check and re-sign your Advance Decision regularly. There is no clear guidance on howregularly you should review your Advance Decision, but the more recent the signature, the more certain the healthcare team will be that what you have said in your Advance Decision is still what you want. If you have an existingcondition or are enrolled in end-of-life care you should talk to your healthcare team about how regularly you shouldreview your Advance Decision. We strongly recommend reviewing and re-signing your Advance Decision if your healthsituation changes, or if you are going into hospital for serious treatment or surgery.

There is space on the front page for you to re-sign your Advance Decision. If you make changes to the content ofyour Advance Decision, you should ask someone to witness your changes. Guidance on suitable witnesses is given onpage 8 of these Guidance Notes. If you change your Advance Decision you should make the change on each of thecopies of your Advance Decision (e.g. copies held by your GP, next of kin, or others) or send a photocopy of therevised Advance Decision to each of these people.

Translating your treatment wishes intoan Advance DecisionThere are several sections in this Advance Decision where you set out your treatment wishes:

Section 1: Allows you to refuse treatment to prolong your life if you have a life-threatening illness (such asterminal cancer), an impairment of the mind or brain (such as Alzheimer’s) or you are in a persistentlyunconscious state (such as a “persistent vegetative state”).

It also allows you to list any other situations you can think of in which you do not want life-saving or some otherform of treatment. This does not mean that you have to list every kind of condition you could ever suffer from:you are talking about situations. So, for instance, you might want to say “I refuse all life-saving treatments if Ihave a condition which will cause my mobility to be permanently impaired to the extent that I will never be ableto sit in a chair independently.” This would mean you were refusing treatments for all the conditions that wouldhave this outcome; it would cover, say, severe stroke, severe head injury, a bleed in the brain, or a neurologicalcondition by which you are severely affected. There is a separate section (Section 3) dealing with treatments andsituations which may arise from a specific condition with which you have already been diagnosed.

The options in Section 1 say that you would not want life-saving treatments in situations where there is “little orno prospect of recovery”. There is no legal definition of “prospect of recovery”. Doctors are obliged to act inyour best interests and it is unlawful for them to discriminate or make judgements about quality of life on thegrounds of age or disability. Therefore, if you have particular ideas about what you consider to constitute a“recovery” you should outline them in Section 4.

Section 2: Allows you to state that you would like to receive all treatment available to alleviate pain anddiscomfort. Unless you have specifically refused pain relief your doctors should still do everything they can tokeep you comfortable, however ticking this box gives you the opportunity to explicitly state you would like to bekept pain-free.

Here you can also state that, if you become pregnant, you wish to receive all treatments to prolong your life if itwould enable the safe delivery of your child, after which your wishes would be reinstated.

Section 3: Allows you to set out your treatment wishes concerning any existing conditions you have. Thisallows you to be more precise than it is possible to be in Section 1, because you will know about the likely


progression and treatment options for your condition. So, for instance, if you have terminal cancer and youhave been told there is a high chance of your contracting pneumonia you could use this section to refusecertain treatments for pneumonia. For example you could refuse all antibiotics for pneumonia or just antibioticsadministered by a drip in a hospital. Likewise, if you have refused certain treatments because of your religiousbeliefs, you can use this Section to explain that that is the reason.

Section 4: Allows you to set out your values and beliefs in general terms. This may help healthcareprofessionals to be clear about when your Advance Decision applies. Say, for example, you said in Section 1 thatyou would not want treatment if there was little chance of recovery from an imminently life threateningcondition. In Section 4 you could supplement this information by explaining that, for you, “little chance ofrecovery” in this situation means being unlikely ever to recover to a point where you could recognise andcommunicate with your loved ones. Likewise, if you have refused certain treatments because of your religiousbeliefs, you can use this Section to explain that that is the reason.

Your treatment wishes will be deeply personal and you will need to think about them carefully. We stronglyrecommend that you discuss your wishes with your GP before filling in the Advance Decision form.

Examples: Person A is fit and healthy with no existing medical conditions but they believe that they would not wanttreatment to keep them alive if they were ever in a persistent vegetative state or a minimally conscious state.They should tick box D in Section 1 and could write a brief statement in Section 4 explaining their reasons andtheir views on quality of life. This will help the doctors to determine at what level of consciousness they wouldlike treatment to be withdrawn.

Person B has been diagnosed with terminal cancer and is expected to die in less than two months. They feelstrongly that they do not want any more treatment to try to prolong their life but want to be as pain free aspossible, even if the painkillers hasten their death. They should fill in Section 1A, 2A, and all of Section 3. Theycould elaborate on their reasons for refusing and requesting treatment in Section 4.

Person C is in their mid-nineties, they have a heart condition which makes them breathless and increases thechance of a heart attack. Other than that they are in good health. They take medication to alleviate thesymptoms of their heart condition (breathlessness) and to stop it deteriorating further. They have decided that ifthey lose capacity they do not want their life prolonged by medication or treatment but that they do want to becomfortable and to make sure that their general health does not deteriorate whilst they are alive. They shouldtick box E in section 1 and write in the space below that they refuse life-saving treatment in all circumstances.They should fill out Section 2 explaining that they would like to receive all treatment to maintain their comfortand Section 4 elaborating on their wishes and reasons for these wishes. They should use Section 3 to identifytheir condition and to explain that, if they lose capacity, they want to continue taking the drugs that alleviate thesymptoms of their heart condition but that they do not want to be resuscitated if they have a heart attack.

Section 1 – Refusal of treatmentIf you want to use your Advance Decision to refuse life-saving treatment you must tick the box at thebeginning of Section 1. If you do not, the request will not be valid. Ticking this box fulfils the legal requirementthat, if an Advance Decision is being used to refuse life-sustaining treatment, it must clearly state that it stillapplies even if the person’s life is at risk.

In Section 1 tick each box if you would like to refuse treatment in the situation described beside that box. Thetreatment you would refuse by doing so is treatment to prolong or sustain your life. You can tick as many ofthe boxes as you like.


(A) Tick the box next to (A) if you want to refuse treatment when you are in a life-threatening conditionfrom which you are unlikely to recover. This includes life-threatening conditions brought about byillness (such as late-stage terminal cancer), injury (such as a car accident) or a pre-existing long termcondition (such as Multiple Sclerosis).

(B) Tick the box next to B if you want to refuse treatment if you have a serious mental impairment withlittle or no prospect of recovery. For example, if you had late-stage Alzheimer’s disease or severe braindamage.

(C) Tick the box next to (C) if you want to refuse treatment when you have been unconscious for a longtime and are unlikely to regain consciousness. You will need to fill in how many weeks you need to havebeen unconscious for before you want treatment stopped.

(D) Tick the box next to (D) if you want to refuse treatment if you have been diagnosed as being in aminimally conscious state or persistent vegetative state for a certain amount of time and are unlikelyto recover. You will need to fill in how many weeks you need to have been in this state for before youwant treatment stopped.

(E) Statements (A), (B), (C) and (D) are designed to cover refusal of treatment should you lose capacity invirtually any situation.

Tick the box next to (E) if you want to explain any other situations where you would want to refuse lifeprolonging treatment, OR any specific treatments that you want to refuse. Then use the space belowthe statement to explain which treatments you would want to refuse in which situations.

If you want to, you can write that you wish to refuse all life-prolonging treatments in everysituation in this section.

You will need to think carefully about this and it is strongly recommended that you discuss yourdecision with your GP, hospital doctor or nurse.

This Section should give clear instructions to medical staff, you do not need to explain why you do notwant treatment. You can explain why you do not want treatment in the Advance Statement (Section 4)if you want to’. There is also a separate Section (Section 3) for you to put in details about treatmentsfor any existing conditions you have.

If you need more space, continue on a separate sheet of paper, attach it securely to your AdvanceDecision and tick the box at the bottom right hand side of the page.

The statement about comfort and personal hygiene at the end of the page means that if you refuse treatment,you will be kept comfortable and your personal hygiene will be maintained.

Section 2 – I wish it to be knownIn Section 2, please tick either box if it is relevant to you.

(A) Tick the box next to A if you wish to state that you would like to receive all treatment available toalleviate pain and discomfort. Unless you have specifically refused pain relief your doctors should stilldo everything they can to keep you comfortable, however ticking this box gives you the opportunity toexplicitly state you would like to be kept pain-free.

(B) Tick the box next to B if, should you become pregnant, you would like to retract the instructions in yourAdvance Decision to ensure the safe delivery of your baby, whereupon the Advance Decision would bereinstated.


Section 3 – Known illnessYou should fill in this section if you have been diagnosed with a specific illness and know that you would orwould not want certain treatments if you lost capacity. (See the example of Person C on page 4 of the GuidanceNotes as an example).

You can also fill in this section if you are about to undergo medical treatments involving risks. For example, ifyour heart stopped during an operation, would you want doctors to attempt resuscitation or not?

You should talk to your doctors about the likely progress of your condition or the risks involved in the medicaltreatments you will receive, as well as the consequences of refusing different treatments. You should also makesure they are aware of your Advance Decision.

If you need more space, continue on a separate page, attach it securely to your Advance Decision and tick thefirst box at the bottom right hand side of the page.

If you have used this section to refuse treatments and would want to do so even if your life may end as a result,tick the second box on the bottom right hand side of the page.

Section 4 – Advance StatementAn Advance Statement (also sometimes called a Statement of Wishes) is a general statement about anything thatis important to you in relation to your future treatment and wellbeing. The directions you write on this page arenot legally binding, however anyone making a decision on your behalf is required by law to consider thesestatements when deciding what is in your best interests.

You can use it to express your preferences for care or to detail any values or beliefs that inform the decisionsyou make. Say, for instance, you have strong religious beliefs that mean that you would never consent to ablood transfusion. You will have used Section 1 to refuse a blood transfusion but you can use this section toexplain why you refuse it.

In the refusal of treatment section of the Advance Decision, statements (A), (B), (C) and (D) apply in situationswhere there is little or no prospect of recovery. If you have strong ideas about what you believe is an acceptablerecovery, you can include these in the Advance Statement. For example, you might want to state whether factorssuch as pain, loss of memory, and recognising and interacting with family and friends, are important to your ideaof ‘quality of life’ and ‘recovery’. You might also want to indicate the relative importance you attach to thesedifferent factors. For example, if you consider recognising friends and family as more important than being freefrom pain, you should say so. This will help medical professionals and your loved ones to understand your wishes.

Stating your values and beliefs will help those treating you to better understand what you want. It will also helpthem to determine how you would want to be treated if you lacked capacity and a situation arose that wasn’tspecified in your refusal(s) of treatment.

If you feel strongly that there are certain treatments you would want to have then you should detail them here. So,for example, if you feel strongly that you would never want artificial nutrition or hydration removed (which isconsidered a medical treatment), you should say so. You do not have the right to demand a medical treatment.This is because doctors do not have to give you treatment just because you ask for it. However, you are entitled torequest a treatment, or to suggest why you feel a certain treatment is right for you. A doctor is not legally obligedto give you the treatment you ask for but they will take your wishes into account when deciding how to treat you.

The Advance Statement can also include instructions, such as who you want doctors to contact if you are takeninto hospital. Any extra information you can provide will be useful to healthcare professionals. Although thedirections you write on this page are not legally binding, completing this Advance Statement will help to ensurethat your wishes, feelings and beliefs are taken into account when any decisions are made on your behalf.


Section 5 – Lasting Power of AttorneyA Lasting Power of Attorney (LPA) is a written document that gives one or more trusted persons the legalpower to make decisions on your behalf if you become unable to make decisions for yourself or the lose theability to communicate. The person who grants power is known as the ‘Donor’ and the person appointed tomake decisions is the ‘Attorney’.

There are two separate types of LPA; a Property and Financial Affairs LPA, which covers areas of your lifewhere money and property are involved, and a Health and Welfare LPA, which relates to decisions about yourhealth, personal care and welfare. Only someone who has been appointed as your Attorney for health andwelfare will be able to make decisions about your healthcare and medical treatment. A property and financialaffairs LPA does not give the Attorney power to make decisions about your healthcare or treatment.

You can only make a LPA by registering it through the Office of the Public Guardian (OPG). You cannot appointan Attorney through an Advance Decision. You should only provide details in this section if you have formallyregistered a health and welfare LPA with the OPG. To find out more about LPAs phone Compassion in Dying on0800 999 2434.

You do not have to have a health and welfare LPA to make an Advance Decision. But if you haveappointed a health and welfare LPA, record it in this section of your Advance Decision.

If you are considering making both a Lasting Power of Attorney and an Advance Decision it is important to bearin mind that the more recent document takes precedence. This means that if you appoint someone as yourAttorney after you have made an Advance Decision your Advance Decision will then become invalid. However,where a person makes a Health and Welfare LPA first and subsequently makes an Advance Decision, which isvalid and applicable in the circumstances, the Advance Decision takes precedence for dealing with thatparticular circumstance.

Enduring Powers of Attorney You may have made an Enduring Power of Attorney (EPAs) for your financial decisions before 2007. EPAs onlycover finance and property and therefore give no power to make healthcare decisions on your behalf sothey do not need to be named on the Advance Decision form.

Section 6 – GP’s Declaration and WitnessesGP’s declarationYou don’t need your GP’s consent to make an Advance Decision but we recommend that you discuss yourwishes with your GP and ask them to witness your mental capacity by signing the declaration on page 6 of theAdvance Decision. This is important because your Advance Decision is only valid if you have mental capacitywhen you fill it out. Having your GP certify that you have mental capacity is a good way to confirm this.However, your Advance Decision is still legally valid even if it is not signed by your GP.

You could also discuss your Advance Decision with your nurse or hospital doctor and ask them to witness thisdocument. Even if your GP does not sign your Advance Decision, they should still keep a copy of it in yourmedical notes.

If your GP refuses to record your Advance Decision contact Compassion in Dying on 0800 999 2434 or [email protected].

Your GP should not charge you for signing an Advance Decision. If they try to do so, contact Compassion inDying for advice.


Section 7 – Witnesses and signing yourAdvance Decision You must have a witness if your Advance Decision says you want to refuse treatment to keep you alive. Legally, onlyone witness is required. This can be any other mentally competent adult (18 years old or over). However, to removeany doubt, it is recommended that you use two witnesses. Likewise, to avoid your Advance Decision being questioned,it is best practice to make sure that at least one of your witnesses is not: your relative or partner; anyone who willinherit your money or property after your death; or anyone you have appointed as your Lasting Power of Attorney.

Your witnesses should watch you sign your Advance Decision and should then add their own signatures andwrite their names and addresses in the spaces provided. They are witnessing you signing your AdvanceDecision, not your ability to sign. You must sign and date your Advance Decision at the bottom of page 7 for it to be valid. If you cannot signyour Advance Decision you can make a mark or ask someone else to sign it on your behalf. Either way, at leastone witness must be present to watch. The witness/es then signs the Advance Decision form in the usual way.

Informing people that you have anAdvance DecisionIt is important that you inform people that you have made an Advance Decision, because if your health teamdoes not know that you have one, they will not know how you wish to be treated.

You should fill in the enclosed Advance Decision form, sign it in the presence of at least one witness, and askyour GP to sign it. We strongly advise you to make at least three photocopies of your completed AdvanceDecision form, so that you can keep one copy yourself, and give the others to anyone involved in your care. Itis very important to give your GP a copy to keep with your medical notes and it is advisable to give one to yourspecialist doctor (if you have an existing health condition) or your local hospital. You should also give a copy toyour next of kin (or a close relative or friend). We suggest that on the photocopied versions of your form, youmake a note of where the original is kept (you might want to keep the original yourself, or give it to your nextof kin). If you are not able to photocopy your Advance Decision form, contact Compassion in Dying on 0800 999 2434 and we will send you extra Advance Decision forms to fill in.

Your Advance Decision comes with a ‘Notice of Advance Decision’ card. You should fill this card in with aballpoint pen and carry it with you at all times.

Additionally, you can register with MedicAlert. MedicAlert provides medical identification jewellery for peoplewho need to convey information in an emergency, for example, that they have an Advance Decision. If you joinMedicAlert ‘Advance Decision’ will be engraved on your jewellery to alert healthcare professionals that youhave made an Advance Decision. MedicAlert will also create a detailed medical record for you, which is heldsecurely and can be accessed 24/7 in an emergency. A copy of your Advance Decision will be held on therecord and be transferred to the hospital immediately if they request it.

You can visit www.medicalert.org.uk or call on 01908 951045 to choose your identification jewellery.

Finally if you have a terminal condition or are approaching the end of life you should speak to your GP aboutwhat local arrangements there are to record your wishes – for example some Ambulance Trusts will holdcopies of people’s Advance Decisions if they have a limited life expectancy. For more information contactCompassion in Dying on 0800 999 2434 or [email protected].

You should also carry your ‘Notice of Advance Decision’ card with you at all times.


Advance Decision checklist Check that you have completed all the necessary steps to make your Advance Decision legally valid and tomaximise the chances of it being followed:

For your Advance Decision to be legally valid you must have:

To help ensure your Advance Decision is known about and followed you should have:

If you have any questions about filling out your Advance Decision please ring the Compassion in Dyinginformation line on 0800 999 2434 for free, confidential support.


• Stated clearly what treatment you would and would not want if you lose capacity.

• Stated clearly the circumstances in which you would or would not want the above.

• Signed and dated your Advance Decision.

• Ticked the box at the top of page 2 confirming that your refusal of treatment applies even if itwill bring about your death (you only need to do this if you are using your Advance Decision torefuse life-saving treatment).

• Had your Advance Decision signed and dated by a witness (you only need to do this if you areusing your Advance Decision to refuse life-saving treatment).

• Signed and dated any changes you have made to your Advance Decision. You must eithermake these changes on each copy of the Advance Decision or send a photocopy of the signedand dated changes to each person who holds a copy of your Advance Decision.

• Asked your GP to sign your Advance Decision to confirm that you had capacity when youcompleted the form.

• Had your Advance Decision signed by a second witness (your GP does not count as one of thewitnesses).

• Ensured the witnesses are in keeping with the recommendations on page 8 of this Guidance.

• Informed those closest to you, your GP, and your healthcare team (if you have one) that youhave made an Advance Decision, and given them copies.

• Securely attached any additional pages to each copy of your Advance Decision

• Discussed your health care and treatment wishes with your GP.

• Filled out your Notice of Advance Decision card and stored it in your purse or wallet and/orjoined MedicAlert.

Compassion in Dying181 Oxford Street London W1D 2JT

Tel: 0800 999 2434 (10am to 4pm, Monday to Friday) Fax: 020 7287 1760Email: [email protected]

www.compassionindying.org.uk

Copyright © Compassion in Dying

Registered Charity in England and Wales, number 1120203

Date published: August 2014

2. FOLD ALONG THIS DOTTED LINE

3. CUT CARD OUT ALONG DASHED LINES

NOTICE OF ADVANCE DECISION CARD1. Print this sheet out on an A4 sheet of paper or A4 card (preferable).

2. Fold along the dotted line.

3. Cut the card out from the sheet.

4. Stick together if required.

5. Fill in the card and carry it with you at all times.

NOTICE OF ADVANCE DECISION

Name

I have a legally enforceable Advance Decision obtainable from:

Name

Address

Phone

18:15

Documents

Advance Decision Pack - Compassion in Dying · Advance Decision Pack Your download document contains: ☐ Advance Decision Form Legal document to register your treatment wishes (PDF