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EUTHANASIA STATEMENT
With this advance directive, which contains both an euthanasia request and a declaration of non-treatment, I address myself to the doctor and furthermore to anyone else who is or will be involved in my medical treatment, care or nursing.
Before I will request Euthanasia, I adequately will let me inform about my situation and medical treatment options by the general practitioner or treating physician and, if necessary, by a psychiatrist or psychologist or by a professional in the field of meaning of life.
Choose from the below, add or remove
1. I want to die with active euthanasia if, for whatever reason, I find myself in a mental and/or physical condition as described in 5., of which I now fully competent declare that in my opinion these conditions offer little or no prospect of return to a state of life that I find reasonable and dignified. If I become incompetent, this provision will continue to apply in full.
2. If this condition in 5. occurs at the discretion of myself or my legal representative if I have become incompetent, I hereby refuse my consent for any life-prolonging treatment. If I find myself in a situation where drastic medical treatments are required to keep me alive, I do not want to be resuscitated or medically ventilated; are not treated in the event of a life-threatening illness; and I don’t want to have surgery in the terminal phase.
3. In the event that I cannot die mildly or with dignity within two weeks due to the omission of (further) medical treatment, I request the doctor to fulfill my dying wish by granting me Euthanasia under his or her guidance. to give or euthanize me. I don’t want terminal palliative sedation.
4. I want to die with active euthanasia when I competently indicate that I consider my life complete and that I therefore am suffering from my meaningless life.
5. In any case, I understand the situation referred to in 1. and 2. to be:
1. in my competent judgment or in the event of being incompetent, in the judgment of my legal representative: serious terminal suffering.
2. in my competent judgment or in the event of being incompetent, in the judgment of my legal representative: greater suffering than I can bear.
3. in my competent judgment or in the event of being incompetent in the judgment of my legal representative: suffering from Alzheimer’s at the diagnosis of the beginning of the third phase.
4. in my competent judgment or in the event of being incompetent, in the judgment of my legal representative: suffering from another form of dementia in an advanced phase.
5. in my competent judgment or in the event of being incompetent in the judgment of my legal representative: the permanent and (almost) total loss of my capacity for mental activity or for communication or for self-reliance.
6. in my competent opinion or in the event of being incompetent in the opinion of my legal representative: having to undergo an unavoidable defamation.
7. suffering terminally for more than three months.
8. becoming dependent on professional care.
9. if I have to be permanently admitted to a healthcare institution.
10.if I have to undergo an irreversible coma.
11.if I can no longer answer the following questions:a. the name of my partner or child(ren) or…b. my date of birth.c. complete with e.g. past events, such as the birth of children, etc.
12.in my competent judgment or in the event of being incompetent in the judgment of my legal representative: any mental or physical condition that I will indicate or that will affect me with unacceptable consequences for me, such as if I become blind or deaf or no longer can speak or no longer can walk or…
Complete the above with what is important to you and remove what is not important to you.
Transfer
If the doctor treating me does not want to comply to 1. to 5, I hereby request the doctor to immediately refer me to a doctor who is willing to comply.
Legal Representatives
My legal representatives represent my interests in every field when I am no longer able to do so myself. I authorize my legal representatives to make choices on my behalf regarding the medical policy that fits within the foregoing statement. I give my medical practitioners permission to provide my legal representatives with all medical information about me (my medical file, even after my death). In the event of differences of interpretation with regard to the foregoing in this statement, the legal representatives are each legal to make the decisions I indicate above in the order of name: FILL IN, Citizen Identification Number: FILL IN and name: FILL IN, Citizen Identification Number: FILL IN.
Confirmation
If, in the condition referred to above, I am still capable of expressing my will, I request the doctor treating me to request confirmation of this statement. In the event of my being incompetent or of an inability to express myself, this statement must be deemed to contain my express will.
Waiver of confidentiality obligation
In the event that my stated request for Euthanasia is met and an investigation is initiated by a competent authority, I hereby release the physician treating me from his or her obligation of confidentiality with regard to the process of euthanasia and I authorize him or her to provide this authority with the information necessary for the investigation.
Risk acceptance
I made and signed this declaration of intent after thorough consideration and of my own free will. It will continue to apply in the future regardless of the further passage of time. I hereby consciously accept the risk that I may no longer be able to revoke my declaration of intent, in order to exclude another risk that is greater for me, namely that I will have to continue living in circumstances that are unacceptable to me.
Validity of the Euthanasia Statement
This advance directive is a written statement recognized by law and must be used in the event that I am no longer able to decide or speak for myself about my medical treatment. The basis for this lies in Article 2, paragraph 2 of the Termination of Life on Request and Assisted Suicide Assessment Act.
Information to the GP
I have deposited this Euthanasia Statement with my GP. Name: FILL IN, address: FILL IN tel number: FILL IN.
Signature
I am well informed about the meaning of this statement and have given careful thought to its drafting. I sign this statement fully competent. If this statement conflicts with any statements previously signed by me, this statement of (date) FILL IN takes precedence.
Signed by Name: FILL IN; Citizen Identification Number: FILL IN; born: FILL IN on FILL IN; and by the legal representatives.
INSERT place of residence, INSERT date.
INSERT ANY WITNESS(S).A copy of this statement has been given to my GP FILL IN on FILL IN.
A copy of this statement is in my personal archive. Copies were provided to (my legal representatives).