APPOINTMENT OF ENDURING GUARDIAN (pursuant to section 6 of the Guardianship Act 1987 NSW) Instrument appointing an enduring guardian

Transcription

1 APPOINTMENT OF ENDURING GUARDIAN (pursuant to section 6 of the Guardianship Act 1987 NSW) Instrument appointing an enduring guardian (encompassing Advance Healthcare Directive) 1. Appointment of enduring guardian I, (Appointer) revoke all other enduring guardianship appointments previously made by me. I appoint:- (Insert - My wife / husband / partner / son / daughter / other) (Insert - My son / daughter / other) (Insert - My son / daughter / other) to be my enduring guardian/s if, because of a disability, I am partially or totally incapable of managing my person. 2. Functions I authorise my enduring guardian/s to exercise the following functions: to decide where I live to decide what health care I receive to decide what other personal services I receive; and to consent to medical or dental treatment for me (in accordance with Part 5 of the Guardianship Act 1987 N.S.W.).

2 3. Directions Page 2 I require that each of my enduring guardians exercise her / his or their functions subject to the following directions: That I wish to reside in my principal place of residence for as long as possible. That my attending physician withhold or withdraw treatment that serves only to prolong the process of my dying, if I should be in a persistent vegetative state or an incurable or irreversible mental or physical condition with no reasonable expectation of recovery. This particular direction applies if I am: (i). (ii). (iii). (iv). (v). (vi). in a terminal condition; or permanently unconscious (coma); or if I am conscious but have irreversible brain damage and will never regain the ability to make decisions and express my wishes; or am suffering from advanced disseminated malignant disease or severe immune deficiency; or suffering from advanced degenerative disease of the nervous system or severe and lasting brain damage due to injury, stroke, disease or any other cause; or Suffering from senile or pre-senile dementia, whether Alzheimer s Disease, multi-infarct or other. That treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing treatment. That if I am suffering from one or more of the conditions referred to above I direct that I do not want: (i). (ii). (iii). (iv). cardiopulmonary resuscitation; or assisted ventilation; or artificial feeding and hydration; or antibiotics. (e) (f) That notwithstanding the foregoing, I do want maximum pain relief. Definitions of terms used in this section terminal: resulting in death- I can reasonably be expected to die within the next twelve months, and this prognosis has been confirmed by a second medical practitioner. terminal phase of a terminal illness: I am dying and the process is not reversible. Attempts at reversing this process are usually futile and may cause me unnecessary pain or distress. Life expectancy is usually considered to be just a few days. Incurable: no known cure irreversible: unable to be turned around - there is no possibility that I will recover. An example of an irreversible illness is Motor Neurone Disease, which progressively paralyses the body. permanently unconscious (coma): when brain damage is so severe that there is little or no possibility that I will regain consciousness.

3 Page 3 persistent vegetative state: severe and irreversible brain damage, but vital functions of the body continue (e.g. heart beat and breathing). Life-sustaining measures These include: cardiopulmonary resuscitation: emergency measures to keep the heart pumping (by massaging chest or using electrical stimulation) and artificial ventilation (mouth-to-mouth or ventilator) when breathing and heart beat have stopped. assisted ventilation: use of a machine, such as a ventilator, to help me breathe when I am unable to breathe unaided. artificial feeding and hydration: provision of food and fluid by artificial means when I am unable to eat or drink. This may be done by passing a tube through the nose into the stomach or by inserting a tube into a vein or directly into the stomach. 4. General This instrument shall confer no authority on my (son/s, daughter/s, etc state name/s) unless my (wife / husband etc state name) has:- (i) (ii) (iii) predeceased me; or declined to accept the authority conferred by this instrument; or become incapable of exercising the authority conferred by this instrument as evidenced by the certificate of a duly qualified medical practitioner who has been appointed by or on behalf of the said (full name of appointee at 1 ). I appoint my (son/s, daughter/s, etc state names) to act jointly and I direct that if either of them shall pre-decease me or become incapable of exercising these functions then the survivor of them shall continue to hold the authority conferred by this Instrument. (Note: should there be other stipulations eg. another family member who has a mild intellectual disability but who should be advised/consulted before action is taken, that should be stated and the person be named here) ( if above is not included) I declare that (i) (ii) I have discussed this appointment with my Medical Practitioner (name/address if considered appropriate) and therefore I am well informed about/acquainted with the import/implications of this appointment, both in general and in relation to Section 2. This is an appointment of an enduring guardian under the Guardianship Act, 1987 N.S.W. Dated this day of (Signature) (Full name of Appointer)

4 Page 4 : (Appointee at 1 ) : (Appointee at 1 ) : (Appointee at 1 )

5 Page 5 Certificate of witness I witnessed the execution of this instrument by (Full name of appointer), and Location, State or Territory, where signatures witnessed:.. New South Wales I witnessed the execution of this instrument by (Full name of appointee at 1 ) and Location, State or Territory, where signatures witnessed:... New South Wales I witnessed the execution of this instrument by (Full name of appointee at 1 ) and Location, State or Territory, where signatures witnessed: New South Wales I witnessed the execution of this instrument by (Full name of appointee at 1 ) and Location, State or Territory, where signatures witnessed:.. New South Wales