My Death, My Decision - Easy Print Advance Decision and Statement of End of Life Wishes

Sep 16, 2026

Uploaded by Fahsai

Easy Print form for recording an Advance Decision and Statement of End of Life Wishes. Includes fields for personal details and contact information for healthcare providers, plus sections to confirm mental capacity and whether decisions were made without coercion. Provides tick-box options on life support treatment and refusals, including specific forms of treatment. Also covers witnessing, signing, review dates, organ donation and anatomical donation status, and notes on how to amend or replace decisions.

LanguageEnglish

CategoryForms

FormatPDF

Pages18

Reading Time6 min

AccessFree to download

Title, name and contact details

Healthcare providers notice and copies distribution

Advance decision capacity and discussion

Capacity confirmation and loss-of-capacity intention

Discussion with GP and other parties

Life support and refusal options

Life support treatment preferences

Refusal including resuscitation, ventilation, feeding tube, antibiotics

Suffering relief and food/drink refusal

Maintain refusal despite life risk

Food and drink refusal and related attempts

Life not preserved in specified conditions

End of Life Choices Your Advance Decision and Statement of End of Life Wishes ( Easy Print) Advance Decisions Do not complete this form without ﬁrst reading the related document: 'End of Life Choices: Your guide to advance decisions and statements of end of life wishes'. Title Name Address ________________________________________________________________ Postcode NHS Number GP Name and Address ________________________________________________________________ My Death, My Decision Limited, a company limited by guarantee, registered in England number 11758121 , registered oące Unit A 39 Moreland Street London EC1V 8BB To my healthcare providers Thank you for your care and for respecting my wishes. If for personal reasons of your own, you feel unable to accept and follow my wishes, please pass my care to someone who can. The following have copies of my Advance Decision (tick as applicable): My GP/ other health professional ( ) Family ( ) Friends ( ) Solicitor ( ) Details (names/addresses/phone numbers): ______________________________________________________________________________________ I have discussed my Advance Decision with (tick as applicable): My GP/ other health professional ( ) Family ( ) Friends ( ) Solicitor ( ) Details (names/addresses/phone numbers): ______________________________________________________________________________________ Tick as applicable At the time of completing this Advance Decision I have mental capacity to make the decisions contained in it. I have carefully considered the decisions I have made and no-one has coerced me. Should I subsequently lose mental capacity through dementia or other irreversible progressive mental condition, I intend for the decisions I have made here to refuse treatment to be valid and my wishes set out here followed. ( ) OR Because I have recently been diagnosed with dementia (Alzheimer’s Disease), I My Death, My Decision Limited, a company limited by guarantee, registered in England number 11758121 , registered oące Unit A 39 Moreland Street London EC1V 8BB have attached a statement from my GP or other health professional conﬁrming that at the time of completing this Advance Decision, I have the mental capacity to make the decisions contained in it. ( ) I want life support treatment (tick as applicable): (I) When I am unable to make or communicate decisions I always want to have life support treatment. ( ) (II) If my doctor believes it could help my health condition or symptoms. ( ) I do not want life support treatment (tick as applicable): (I) If two health professionals decide that I am likely to die within a short period of time. ( ) (II) If two health professionals decide I have permanent and severe brain damage, I have severe dementia or I am in a coma from which I am not expected to recover. ( ) (III) If life support treatment would only delay the moment of my death. ( ) (IV) If life support treatment begun before I lost capacity is not helping my health condition or symptoms, I want it stopped. ( ) This refusal includes but is not limited to (tick as applicable): Cardio-pulmonary resuscitation ( ) Ventilation ( ) A feeding tube ( ) Antibiotics for a potentially life-threatening infection ( ) Specialised treatment for particular conditions (e.g.chemotherapy) ( ) Other: (say what these are) | | | --- | | | My Death, My Decision Limited, a company limited by guarantee, registered in England number 11758121 , registered oące Unit A 39 Moreland Street London EC1V 8BB I maintain this refusal even if it risks or shortens my life. ( ) I want everything possible to be done to relieve my suffering and distress, even if it risks or shortens my life. ( ) If I refuse food and/or drink by mouth, I refuse repeated attempts to feed/hydrate me; or being persuaded or cajoled to eat or drink-even if this refusal risks or shortens my life. ( ) I do not want my life to be preserved

FAQs

What sections does this Easy Print form include for Advance Decisions?

It includes your personal details, copies distribution to relevant people, confirmation of mental capacity, and tick-box options for life support treatment and refusals.

How does the form handle mental capacity if you later lose it due to progressive illness?

It asks you to confirm that you have mental capacity when completing the decision and that, if you later lose capacity, the decisions are intended to refuse treatment and be followed.

What does the form ask you to specify regarding life support and refusal types?

It provides choices on whether you want life support treatment in certain circumstances and lists specific refusals such as resuscitation, ventilation, feeding tubes, antibiotics, and other specialized treatments.

Sep 16, 2026

Uploaded by Fahsai