Advance Decision to Refuse Specified Medical Treatment
1. I, _ (print or type full name),
born _ (date) complete this document to set
forth my treatment instructions in case of my incapacity. The refusal of specified
treatment(s) contained herein continues to apply to that/those treatment(s) even if
those medically responsible for my welfare and/or any other persons believe that
my life is at risk.
2. I am one of Jehovah’s Witnesses with firm religious convictions. With full realization
of the implications of this position I direct that NO TRANSFUSIONS OF BLOOD
or primary blood components (red cells, white cells, plasma or platelets) be
administered to me in any circumstances. I also refuse to predonate my blood for later
infusion.
3. No Lasting Power of Attorney nor any other document that may be in force should be
taken as giving authority to disregard or override my instructions set forth herein. Family
members, relatives, or friends may disagree with me, but any such disagreement does not
diminish the strength or substance of my refusal of blood or other instructions.
4. Regarding end-of-life matters: [initial one of the two choices]
(a) I do not want my life to be prolonged if, to a reasonable degree of medical
certainty, my situation is hopeless.
(b) I want my life to be prolonged as long as possible within the limits of generally
accepted medical standards, even if this means that I might be kept alive on machines for
years.
5. Regarding other healthcare and welfare instructions (such as current medications,
allergies, medical problems or any other comments about my healthcare wishes):
_
dpa-E Bi 1/16 Page 1 of 2
6. I consent to my relevant medical records and the details of my condition being shared with
the Emergency Contact below and/or with member(s) of the Hospital Liaison Committee
for Jehovah’s Witnesses.
7. __________________________________________________________ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ___________________________________________________________
Signature NHS No. Date
______________________________________________________________________________________________________________________________________________________________________________________________________
Address
8. STATEMENT OF WITNESSES: The person who signed this document did so in my
presence. He or she appears to be of sound mind and free from duress, fraud, or undue
influence. I am 18 years of age or older.
______________________________________________________________________________________________ ______________________________________________________________________________________________
Signature of witness Signature of witness
______________________________________________________________________________________________ ______________________________________________________________________________________________
Name Occupation Name Occupation
______________________________________________________________________________________________ ______________________________________________________________________________________________
Address Address
______________________________________________________________________________________________ ______________________________________________________________________________________________
______________________________________________________________________________________________ ______________________________________________________________________________________________
Telephone Mobile Telephone Mobile
9. EMERGENCY CONTACT:
__________________________________________________________________________________________________
Name
__________________________________________________________________________________________________
Address NO BLOOD
__________________________________________________________________________________________________
(signed document inside)
__________________________________________________________________________________________________ Specified Medical Treatment
Telephone Mobile
Advance Decision to Refuse
10. GENERAL PRACTITIONER CONTACT
DETAILS: A copy of this document is
lodged with the Registered General
Medical Practitioner whose details Advance Decision to Refuse
appear below. Specified Medical Treatment
(signed document inside)
NO BLOOD
__________________________________________________________________________________________________
Name
__________________________________________________________________________________________________
Address
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Telephone Number(s)
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