Euthenasy Statement

Name: Kooijman Autar
Price range: $

Download as pdf

Me,

name:

given names:

born at

address myself, with this declaration of will, to the physician and further to any other person who is or will be involved in my medical treatment, nursing and care.

Refusal of treatment/euthanasia request

When, for whatever reason, I find myself in a mental or physical condition which offers little or no prospect of returning to a state of life that is reasonable and dignified for me, I do not wish to continue living and I wish to die soon in a gentle manner.
By the above condition I understand in any case:
1. a state of severe or prolonged terminal suffering;
2. an irreversible coma;
3. the permanent and (almost) total loss of my capacity for mental activity or for communication or for recognition of my neighbor(s);
4. an inescapable disenchantment;
5. any mental or physical condition, which I could specify or which may affect me with consequences apparently unacceptable to me.
In case this condition occurs, I hereby refuse my consent to any life-extending treatment.
In the event that I am unable to die soon in a mild manner due to the absence of (further) medical treatment, I hereby urge the physician treating me to fulfill my wish to die by administering to me the means for a mild death or having me take them under his supervision.

Confirmation

In case I am apparently still able to express my will in the state referred to under 1, I request the physician treating me to obtain from me a confirmation of this declaration. Otherwise, this declaration must be deemed to imply my express will.

Transfer

In the event that the physician treating me is unable or unwilling to comply with my request mentioned under 3, I request him to refer me without delay to a physician who is able or willing to do so.

Waiver of confidentiality

In the event that my request as stated under 3 is complied with and an investigation into this matter is conducted by a competent authority, I hereby release the physician treating me from his obligation of secrecy regarding my latest suffering and allow him to provide this authority with the information necessary for the investigation.

Risk acceptance

I have made and signed this will after thorough consideration and of my own free will. It remains valid regardless of the passage of time.

I thereby consciously accept the risk that, if I am in the situation referred to under 1, I may no longer be able to revoke my declaration of will in order to exclude another greater risk for me, namely that I will have to live on in circumstances that are not acceptable to me.