[{"id":"a61fd703-f52e-4264-8497-c92c01817b51","order":1,"text":"ADVANCE DECISION TO REFUSE TREATMENT","fontSize":"20","textAlign":"center","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"marginTop":"0"},{"id":"6d6ff793-26d7-4887-813b-bc6b4526ad5a","order":2,"text":"(also known as a Living Will)","fontSize":"14","textAlign":"center","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"05d1ca8a-e10c-4c93-ba21-02acdd161be1","order":3,"text":"Made pursuant to sections 24 to 26 of the Mental Capacity Act 2005","fontSize":"12","textAlign":"center","bold":false,"underline":false,"marginBottom":"40","cflou":false,"active":true},{"id":"89a938cd-5d8d-4cd4-8e4e-46e973e4ad85","order":4,"text":"MADE BY:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"20ed85bc-6bb0-4235-a393-489d921fbca1","order":5,"text":"[Title] [Full name of declarant]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"177f074d-59c3-412d-9ec4-e53b5bca2dd5","order":6,"text":"Of [Address], [Postcode]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"f2a9bef4-b7fc-4e1f-abde-095dc239606e","order":7,"text":"Date of birth: [Date of birth] | Place of birth: [Place of birth]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"e0f76fb7-ae30-47b9-909a-20ea504dfe77","order":8,"text":"NHS Number: [NHS Number] | Telephone: [Telephone]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"af985e7b-2956-4d81-a6a1-09f77fa1c63f","order":9,"text":"1. PURPOSE AND LEGAL EFFECT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20"},{"id":"2378d628-d503-420b-b79f-b440ef245910","order":10,"text":"I, [Title] [Full name], being of full age and of sound mind, hereby make this Advance Decision to Refuse Treatment in accordance with sections 24 to 26 of the Mental Capacity Act 2005 (\"the Act\").","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"4c47cbf3-89f1-4d0d-b8a7-189e26242e4a","order":11,"text":"I make this Advance Decision freely, after careful reflection, and without coercion or undue influence. It is intended to record my settled wishes regarding the medical treatment I am to receive, or am not to receive, in the event that I lack the mental capacity to give or refuse consent to such treatment myself.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f51d994d-9050-448f-b6be-1c1a58a79442","order":12,"text":"I understand that, provided this Advance Decision is valid and applicable to the circumstances which subsequently arise, it shall have the same legal effect as a contemporaneous refusal by a person with full mental capacity, and that any treating clinician who knowingly disregards it may be liable in civil law and to professional disciplinary action.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"60f8b16a-d2f2-43ec-b624-d61b7d291cfb","order":13,"text":"2. WHEN THIS DECISION APPLIES","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"7b104c44-c196-4c5e-9d0b-b6453a871d04","order":14,"text":"This Advance Decision shall take effect only at such time as I have lost the mental capacity to give or refuse consent to the treatments referred to herein, and shall continue in force throughout any subsequent period during which I lack such capacity.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"29247200-9e51-477e-b203-1c7998ba8adc","order":15,"text":"It is my wish that this Advance Decision shall apply in any of the following clinical circumstances:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"55aa9b70-cf47-4e8a-87b2-02f109974f1d","order":16,"text":"• I have a terminal illness from which I am not expected to recover;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"ce2f1f9f-ef67-4460-9c4f-db1f98959d90","value":"1","type":"add","operator":"="}]},{"id":"725f7840-b7cc-480f-a1b2-6f4fd1417eb8","order":17,"text":"• I am permanently unconscious (a persistent vegetative state) with no reasonable prospect of regaining consciousness;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"8af62b3a-b7a8-4cad-aba3-2399913825ef","value":"1","type":"add","operator":"="}]},{"id":"76d2cf3d-cac8-40b8-9105-a1887e291cb6","order":18,"text":"• I am suffering from an advanced and progressive condition such as advanced dementia, motor neurone disease or end-stage organ failure, with no reasonable prospect of meaningful recovery;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b037d766-6723-4f6b-b570-85868e578500","value":"1","type":"add","operator":"="}]},{"id":"9ee9e933-3d3d-4bf2-bcd3-11ffe58d5501","order":19,"text":"• I have severe and irreversible brain damage and am unable to communicate or recognise those close to me;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"2598bcc0-76f8-4e14-9793-6c0487d35a2b","value":"1","type":"add","operator":"="}]},{"id":"a8ca686b-c08b-424c-8c18-370d8d66ddbd","order":20,"text":"3. TREATMENTS REFUSED","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"6dbe2ae1-6099-4834-86eb-91af409299f9","order":21,"text":"In the circumstances described in clause 2 above, I, [Full name], refuse the following medical treatment(s):","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"17d3e570-20ea-43dd-9ed5-d499b56c127e","order":22,"text":"• renal dialysis;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"5e2761e0-d14e-4e05-9d22-cad220b1df08","value":"1","type":"add","operator":"="}]},{"id":"2627091a-98b2-4f45-89a7-5cf5d8b67eae","order":23,"text":"• chemotherapy or radiotherapy;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"fa3b2844-1325-40f6-b3e5-683cdd87e007","value":"1","type":"add","operator":"="}]},{"id":"3b7d5f3d-14fe-4f0d-9ecc-952716a9e570","order":24,"text":"• cardio-pulmonary resuscitation (CPR);","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"a139f569-7229-40f3-b5ee-92117375caa4","value":"1","type":"add","operator":"="}]},{"id":"b864c9f5-8281-4217-af74-867a02d524ef","order":25,"text":"• artificial nutrition and hydration (clinically assisted feeding by tube or drip);","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"e855c6ec-4a9a-4f29-9f31-1da45696d90f","value":"1","type":"add","operator":"="}]},{"id":"c29ea485-7e81-4725-b792-3ddd4028cc09","order":26,"text":"• antibiotics for life-threatening infection;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"13858bf3-cdae-4517-b20f-dd9992191b6f","value":"1","type":"add","operator":"="}]},{"id":"c40ed893-f7ee-4b77-bb93-cdc0006d59fa","order":27,"text":"• blood transfusion;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"12aed5c5-8564-49f2-9779-0002d619559b","value":"1","type":"add","operator":"="}]},{"id":"ff15ebb8-f47c-4724-97b5-f38a254fb62c","order":28,"text":"• artificial (mechanical) ventilation;","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"97704556-efc9-48d7-8327-8036763c5514","value":"1","type":"add","operator":"="}]},{"id":"1091cb85-e5c7-49d0-b8dd-c46acbd6df6b","order":29,"text":"I further refuse: [Any other treatments]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"2904792f-d38c-4fa9-b950-db5924f54661","order":30,"text":"4. LIFE-SUSTAINING TREATMENT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"8b5d1fc2-3a5b-4549-aee0-9157cb0c21e3","order":31,"text":"I have considered carefully the consequences of refusing treatment in the circumstances described above, including the foreseeable consequence that such refusal may result in my death. I confirm the following statement, as required by section 25(5) of the Mental Capacity Act 2005:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"cda27377-95f5-4af8-bfdf-42916ce07678","order":32,"text":"[Life-sustaining treatment statement].","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"32d98b6b-d1c1-4818-8071-db7d83c2df73","order":33,"text":"5. COMFORT CARE AND PALLIATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"1e82cad9-c5ea-4a8d-94d5-c732d64e655a","order":34,"text":"Notwithstanding any refusal expressed above, [Comfort care preference]. Such basic care includes, without limitation, warmth, shelter, oral hygiene, repositioning to prevent pressure sores, and the offer of food and water by mouth.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"76551bb7-e3be-407f-9b4f-156f1cb41891","order":35,"text":"Furthermore, [Pain relief preference].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"e62ca433-8aa9-4f07-9842-b6948d4f900d","order":36,"text":"6. GENERAL PRACTITIONER","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"14155a24-52b2-4d6b-951c-70ba91122142","order":37,"text":"My registered General Practitioner is [GP name] of [GP practice], [GP address], telephone [GP telephone]. A signed copy of this Advance Decision has been, or shall be, lodged with my General Practitioner.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"94cf548c-0e6c-4e93-b718-e29a7dec65f0","order":38,"text":"7. LASTING POWER OF ATTORNEY","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"6abe11fe-46e3-462a-b8dc-f32e341e8f01","order":39,"text":"I have not appointed any Lasting Power of Attorney for Health and Welfare under section 9 of the Mental Capacity Act 2005. Accordingly, no such attorney exists who could override the terms of this Advance Decision.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b0aac4b7-7fba-428d-8946-eb24db945d23","value":"No","type":"add","operator":"="}]},{"id":"822ac0f0-02c1-475c-93d7-c87036bf42e2","order":40,"text":"I have appointed [Attorney name] of [Attorney address] as my attorney under a Lasting Power of Attorney for Health and Welfare. I confirm that this Advance Decision was made by me after the said Lasting Power of Attorney, and that to the extent of any inconsistency the terms of this Advance Decision shall, by virtue of section 25(2)(b) of the Mental Capacity Act 2005, prevail.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"b0aac4b7-7fba-428d-8946-eb24db945d23","value":"Yes","type":"add","operator":"="}]},{"id":"01850eaf-d655-44f8-8f58-9db946a54304","order":41,"text":"8. VALIDITY AND APPLICABILITY","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"c19a4c5c-ce40-496e-a3b8-02dafced7ca8","order":42,"text":"I declare that, at the date of signing this document, I am aged eighteen years or over and I have the mental capacity to make this Advance Decision. I have not been subjected to any duress, fraud or undue influence. I have given full and careful consideration to the matters herein, and have, where appropriate, taken medical advice as to the nature and consequences of the treatments refused.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"37f47e9d-ced2-4daa-8c70-360a5d5d7b56","order":43,"text":"I reserve the right at any time, while I retain mental capacity, to revoke or amend this Advance Decision in whole or in part. Any such revocation or amendment shall not be required to be in writing, save that an amendment relating to the refusal of life-sustaining treatment must comply with the formalities of section 25(6) of the Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"7c073186-995e-4d2f-8b5b-76849b3dc5d7","order":44,"text":"Should there be reasonable grounds to believe that, at the material time, the circumstances which have in fact arisen were not anticipated by me and would, had they been anticipated, have affected my decision, this Advance Decision shall not apply to those circumstances and treatment shall be determined in accordance with the best-interests checklist set out in section 4 of the Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"917fdd8b-63bb-4e2c-8984-91cd004702f1","order":45,"text":"9. IDENTIFICATION","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"10"},{"id":"8153363c-5291-4ad4-9650-b645e48003a0","order":46,"text":"For the avoidance of doubt, the following distinguishing features may assist in confirming my identity in the event of incapacity: [Distinguishing features].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"f282db67-60c0-4506-bfe7-3dac40c8d9b0","order":47,"text":"SIGNED BY THE DECLARANT","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"30"},{"id":"00590515-30a4-43d2-8b20-530bed5ab6d9","order":48,"text":"Signed at [Place of signing] on this day, [Date].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"ec8bc9ec-158f-4a51-b123-c871340e26c0","order":49,"text":"[Title] [Full name]","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"18586f44-5e53-4d8b-bac8-e950e850963a","order":50,"text":"Declarant — Signature: ____________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"47f22c0f-5abe-49fb-8911-8f869c01f88c","order":51,"text":"WITNESSED BY:","fontSize":"16","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20"},{"id":"bb4c294b-7345-467a-9f09-f878378abeb6","order":52,"text":"I, [First witness — name] of [First witness — address], [First witness — occupation], hereby declare that I have witnessed the signing of this Advance Decision by [Title] [Full name] on the date stated above. I confirm that the Declarant signed this document in my presence, that they appeared to me to be of sound mind, and that I have no interest, financial or otherwise, under any will, codicil or other testamentary instrument of the Declarant, nor have I been appointed as their attorney under any Lasting Power of Attorney.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"c03231c7-6b68-48fa-936a-73c9bfac2c13","order":53,"text":"[First witness — name]","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"032c0fdc-7b3e-4499-b323-0500102cbf40","order":54,"text":"First Witness — Signature: ____________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"330a349b-68be-4665-92da-919d2659cc59","order":55,"text":"I, [Second witness — name] of [Second witness — address], [Second witness — occupation], hereby declare that I have witnessed the signing of this Advance Decision by the Declarant named above on the date stated. I confirm that the Declarant signed this document in my presence, that they appeared to me to be of sound mind, and that I have no interest, financial or otherwise, in their estate, nor have I been appointed as their attorney under any Lasting Power of Attorney.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"703b7cea-a30c-4a83-807b-ff67ee7ef8d6","order":56,"text":"[Second witness — name]","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"3b51f684-ca8d-416b-a0c7-54bf4c5daa85","order":57,"text":"Second Witness — Signature: ____________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"c57e0a25-cab2-4946-9867-c6268b31ea2c","order":58,"text":"Executed on [Date] — all parties signing on the same day.","fontSize":"12","textAlign":"center","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true,"marginTop":"20"},{"id":"c862b59f-be7a-4576-bf80-d00fafbaf124","order":59,"text":"FOR THE ATTENTION OF TREATING CLINICIANS","fontSize":"14","textAlign":"left","bold":true,"underline":true,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20"},{"id":"04906638-c2d8-42a9-9e4d-55fdd4e91a7e","order":60,"text":"This document is a valid Advance Decision to Refuse Treatment made by [Full name], born on [Date of birth] and residing at [Address], [Postcode]. Please incorporate a copy in the patient's medical record and notify the General Practitioner identified at clause 6 above.","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e4430504-8967-4ad2-bf2c-70201ffc794d","order":61,"text":"If you have any doubt as to the validity or applicability of this Advance Decision, you are referred to chapter 9 of the Mental Capacity Act 2005 Code of Practice. In case of clinical urgency, treatment necessary to preserve life or prevent serious deterioration in the patient's condition may be administered while the validity and applicability of this document are being investigated, in accordance with paragraph 9.59 of the said Code.","fontSize":"11","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"1b7a0caa-9898-4c90-b534-8b6c56b974d6","order":9999,"text":"Advance Decision to Refuse Treatment — Mental Capacity Act 2005, ss. 24–26","fontSize":"10","textAlign":"center","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true,"isFooter":true}]