Advance Health Care Directive printable pdf download

Advance Health Care Directive

ADVANCE HEALTH CARE

DIRECTIVE

of the

Cancer Association of South

Africa (CANSA

Introduction

This document is made available so that an adult individual can give specific instructions

about any aspect of his/her health care. Choices are provided for the person completing this

document to express his/her wishes regarding the provision, withholding, or withdrawal of

treatment to keep him/her alive, as well as the provision of pain relief. Space is also provided

for the individual to add to the choices they have made or to write out any additional wishes.

This form also lets the individual express an intention to donate his/her bodily organs and/or

tissues following his/her death. Lastly, this form makes provision for the individual to

designate a physician to have primary responsibility for his/her health care.

After completion of this form, all signatories to this Advance Health Care Directive must sign

the document in the space provided as well as initial every single page of the document. The

document must also be signed by two qualified witnesses or acknowledged before a Notary

Public or Commissioner of Oaths. A certified copy of the signed and completed Advance

Health Care Directive should be provided to the elected primary care physician, to any other

health care provider(s) the individual may have indicated, to any health care institution at

which the individual normally receives care, and to any health-care agent(s) the individual

may have named.

_________________________________________________________________________

[Full Name(s) and Surname]

being of sound mind and at least 18 years of age, declare that:

End-of-Life-Decisions

I direct that my health care providers and others involved in my care provide, withhold, or

withdraw treatment in accordance with the choice I have marked below: (only one box must

be initialled)

Choice NOT To Have my Life Prolonged

Advance Health Care Directive