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
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A. – ACKNOWLEDGEMENT
BY PATIENT
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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
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B. EXPLANATION
OF TERMS
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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
________________________________________________________________________________
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C.
EXPLANATION OF TERMS
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·
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
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D. PERSON
AUTHORIZED TO GIVE CONSENT ON MY BEHALF
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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
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Instructions (if any) for the person consenting/making decision on
patient’s behalf
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
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E. Signatures
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Name
and signature of the person giving advance directive
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Date / Time
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Signature of person authorized
for consent/decisions:
I am willing to make decisions/consent on healthcare related matter on
patient’s behalf
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Name,
signature and relationship of the person (First choice)
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Date
/ Time
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Name,
signature and relationship (Second choice)
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Date
/ Time
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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”
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Name
and signature of Witness number 1
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Date / Time
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Name
and signature of Witness number 2
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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”
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Name,
signature and District of JMFC (With official stamp)
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Date / Time
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