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Advance Decision to Refuse Treatment - Template Form

✓ Valid in United Kingdom

Create your Advance Decision to Refuse Treatment - Template Form for use in United Kingdom. Answer a few plain-English questions and the document fills in automatically as you go — then download it in Word and PDF, ready to sign or share.

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Advance Decision to Refuse Treatment - Template Form
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Advance Decision

By: ________ of

________

Date of Birth: ________

GP:

________ of

________

To whom it may concern,

1. I make this advance decision and it is addressed to any person who may be responsible for my health care in the future, including my family and any healthcare professional.

2. The contents of this advance decision have been carefully created by me of my own free will, while I have the capacity to do so.

3. I have also discussed the contents of this advance decision with my GP.

4. If at any time after I make this advance advance decision:

4.1. I lack capacity to give consent or to refuse consent to healthcare or treatment within the meaning of the Mental Capacity Act 2005; AND

4.2. the Specified Circumstances listed below arise; THEN

4.3. none of the Specified Treatments will be administered to me or continued.

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

6. The Specified Circumstances are any of the following circumstances (which must be verified and confirmed by at least two qualified medical doctors):

6.1. constant, unremitting pain and there is no real prospect of improvement or recovery;

6.2. I am physically paralysed and there is no reasonable prospect of a substantial recovery ;

6.3. any serious impairment of the mind or brain so that I cannot take care of myself independently and with dignity ;

6.4. unconsciousness or coma from which it is unlikely that consciousness will ever be regained;

6.5. a persistent vegetative state and it is unlikely that their full cognitive functioning will ever be regained

7. In this advance decision Specified Treatments shall mean:

7.1. Cardiopulmonary resuscitation

7.2. Artificial nutrition and hydration

7.3. Artificial Respiration

7.4. The following Specified Treatments shall also include:

________



SIGNED:

_________________

________

DATED:

_________________



Signed in the presence of:

NAME OF WITNESS:

_________________

SIGNATURE OF WITNESS

_________________

ADDRESS OF WITNESS:

__________________

OCCUPATION OF WITNESS:

__________________




RECORD OF REVIEW:

REVIEWED BY THE DECISION MAKER AS FOLLOWS:



REVIEWED BY ________ ON ______(day) _______ (month) _______(year)

Signed: ___________________________





REVIEWED BY ________ ON ______(day) _______ (month) _______(year)

Signed: ___________________________





REVIEWED BY ________ ON ______(day) _______ (month) _______(year)

Signed: ___________________________





REVIEWED BY ________ ON ______(day) _______ (month) _______(year)

Signed: ___________________________

Fields you complete are inserted into the document live. This template is general guidance only — not legal advice.