Free Living Will - Ireland

Free Living Will - Ireland

  1. Answer a few simple questions
  2. Print and download instantly
  3. Takes just 5-10 minutes

Create Your Free
Living Will - Ireland

  1. Answer a few simple questions
  2. Email, download or print instantly
  3. Just takes 5 minutes

Living Will - Ireland

Create Your Living Will

Create Your Living Will

Who will this Living Will be shown to?





Frequently Asked Questions
Is my Living Will legally enforceable?In Ireland, a Living Will or Health Directive is legally referred to as an Advance Healthcare Directive. If your Advance Healthcare Directive is properly executed and deals with any proposed treatment, it will be legally binding upon your doctors to follow your instructions.When will my Living Will come into effect?An Advance Healthcare Directive will come into effect only if you lose capacity to make decisions.

A person lacks the capacity to make a decision if he or she is unable to:
  1. understand the information relevant to the decision,
  2. retain that information long enough to make a voluntary choice,
  3. use or weigh that information as part of the process of making the decision, or
  4. communicate his or her decision (whether by talking, writing, using sign language, assistive technology, or any other means).


Your Living Will

Update Preview
This document preview is formatted to fit your mobile device. The formatting will change when printed or viewed on a desktop computer.
Living Will Page of
Page of

ADVANCE HEALTHCARE DIRECTIVE

An Advance Healthcare Directive (AHD) is a written statement made by a person who has reached the age of 18 years with capacity (the ability to understand, retain and use or weight up the information in order to make a decision). It sets out preferences about treatment decisions that they do not want to receive in the future, if a time comes where they lack capacity to make such decisions or cannot communicate their decision by any means.

The Assisted Decision-Making (Capacity) Act 2015 was enacted in December 2015. While AHDs have been recognised in Ireland for many years, there was no law governing them and this led to confusion. The 2015 Act sets out the requirement for making a valid AHD.

AHDs mainly concern a person’s right to refuse treatment even if the refusal is considered by others to be unwise, made for non-medical reasons or may result in death provided that the person making the directive had the decision-making capacity at the time of making the AHD.

The 2015 Act provides that a request for specific treatment set out in an AHD is not legally binding (a person cannot demand treatment that is unnecessary) but it must be taken into consideration if it relates to treatment that is relevant to the medical condition of the maker of the advance healthcare directive.

If the AHD is valid and applicable to the specific treatment then doctors are legally bound to follow them. An AHD can be revoked or altered in writing provided the person has the capacity to do so. Any alteration of an AHD must be signed and witnessed in the same manner as the original AHD.

An AHD also allows you to nominate a Designated Healthcare Representative. This is someone who you will authorise to interpret your AHD or to make healthcare decisions on your behalf. They can have as much authority as you decide to give them, up to and including the power to consent to/refuse life-sustaining treatment on your behalf.

There is no obligation to make an Advance Healthcare Directive. It is completely your decision. This section simply provides you with a space to record any preferences you may have in a way which will meet the requirements for a valid Advance Healthcare Directive.

Importantly, an Advance Healthcare Directive will come into effect only if you lose capacity and are unable to communicate your healthcare decisions.

This information should be shown to:
Family  [ X ]          GP, Nurse, Carer  [ X ]          Other  [     ]

SECTION 1: KEY INFORMATION (IN CASE OF EMERGENCY (ICE))
This section provides key information about you that can be used to inform your treatment and care in case of emergency.

1.1 Personal Information

Name:
____________________

Address:
____________________, _______________
County Carlow, Ireland

Phone number:
__________

 

Gender:
Male

Date of Birth:
11 December 2019

1.2 Emergency Contacts
Who would you like to be contacted in the event of an emergency?
It is important to name more than one person if possible, in case someone is not contactable. You may decide to nominate a family member, friend, your doctor or a neighbour as your contacts. It is very important that you tell them that you are naming them as your emergency contacts, and that you discuss what is involved with them.

Name:

Relationship:

Phone:

Address:

__________________

______________

__________

____________________, ____________________, County Carlow, Ireland

Have you been hospitalised for a serious illness in the last 5 years?
Yes  [     ]                    No  [ X ]

1.4 General Practitioner (GP)/Treating Doctor

Name:
____________________

Address:
____________________, _______________
County Carlow, Ireland

 

Phone:
__________

Email:
__________

1.5 Health Insurance Information
Do you have a medical card?
Yes  [ X ]                    No  [     ]

General Medical Services (GMS) Number:
(on the front of your card)
__________

Private Health Insurance
Do you have private Insurance?

Yes  [     ]                    No  [ X ]

Medications
If you are taking any ongoing medication, you can list those medications below. You might also consider asking your pharmacist to print a record of these on your next visit which you can staple to this page.

Please list all your current medications:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

SECTION 2: CARE PREFERENCES
This section provides key information about you that can be used to inform your treatment and care in case of emergency.

2.1 Care Preferences Information

Other Wishes

Think about the place you would most like to be cared for if you were nearing death.

Please indicate your first preference by putting the number ‘1’ beside that option. Likewise, please put the number ‘2’ beside your second preference, ‘3’ beside your third preference and so on.

Name of preferred hospice: __________________________________________

 

Home

Hospice

Hospital

Nursing Home

[1]

[2]

[3]

[4]

2.2 Designated Healthcare Representative
This section allows you to appoint a Designated Healthcare Representative if you wish. This person may be a trusted family member or a close friend, and will be able to speak for you if you lack the capacity to communicate your wishes. Therefore, it is important to speak to him or her regarding the care you would like or not wish to have.You do not have to appoint a representative and can merely set out your wishes in an Advance Healthcare Directive provided the formalities are followed, signed and witnessed by two persons.

If you decide to nominate a representative, they must be over 18 years of age, not someone who is caring for you in return for payment, and not someone who owns or works in a residential or healthcare facility where you are living. It is necessary for this person to sign the directive and confirm their willingness to carry out your wishes.

Your Designated Healthcare Representative

Name:
__________________

Relationship:
__________________

Address:
____________________, ____________________, County Carlow, Ireland

Phone:
__________

Email:
__________

I am willing to carry out the will and preferences of the directive-maker

________________________________________
Signature of designated healthcare representative

I have given my Designated Healthcare Representative the following authority:

[ X ]  Power to advise and interpret what my wishes are regarding treatment which I have set out in
         this AHD.
[ X ]  Power to ensure that the wishes I have expressed in this Advance Healthcare Directive are
         carried out based on my will and preferences according to my directive.
[ X ]  Power to consent to or refuse medical treatment on my behalf, up to and including
         life-sustaining treatment based on my will and preferences according to my directive.

2.3 Treatment Directions and End-Of-Life Decisions
Please state your directives with respect to life-sustaining treatment and cardiopulmonary
resuscitation (CPR) here. These wishes will have an impact if you become unable to take part effectively in decisions regarding your medical treatment.

Life-Sustaining Treatments
Life-sustaining treatment* is treatment which replaces, or supports, a bodily function which is not operating properly or failing. Where someone has a treatable condition, life sustaining treatments can be used temporarily until the body can resume its normal function again. However, sometimes the body will never regain that function.

If there is no prospect for my recovery:
[ X ]  I wish to have whatever life-sustaining treatments that my healthcare professionals may
         consider necessary and appropriate.

         OR

[     ]  I wish to have whatever life-sustaining treatments that my healthcare professionals may
         consider necessary unless this will require the following treatments, which I do not wish to
         receive, even if this refusal will result in my death:
         [     ]  Being place on a mechanical ventilator/breathing machine
         [     ]  Dialysis
         [     ]  Artificial feeding intravenously
         [     ]  Artificial feeding through a tube in the nose (nasogastric tube)
         [     ]  Artificial feeding through a tube in the abdomen (PEG tube)

Cardiopulmonary Resuscitation* (CPR)
In order to make decisions regarding resuscitation preferences, it is important to discuss your health with your doctor as some conditions will not benefit from CPR.

Preference regarding CPR:

[     ]  I do NOT want CPR.

         OR

[ X ]  I would only like CPR attempted if my doctor believes it may be medically beneficial.

SECTION 3: ORGAN DONATION
Organ donation and transplantation currently saves the lives of between 200 and 250 people in Ireland every year. Each organ and/or tissue donor could save the lives of up to 8 people who are in the end-stage of organ failure.

Organs that are suitable for transplant are the heart, heart valves, kidneys, liver, lungs and pancreas. You may wish to donate all, or some, of these. Only those which have been specifically consented to are taken for transplantation.

It is advisable to inform your loved ones that you wish to donate organs as they may be consulted on this matter. If you do not wish to donate organs you should state this here (in ‘Other’ question).

Having a medical condition does not necessarily prevent you from becoming a donor, however, this will be decided by a healthcare professional on a case-by-case basis. It is advisable to inform your loved ones of your wishes in relation to organ donation as they may be consulted on this matter.

The removal of organs is carried out with the same care and respect as any other operation and organ donation does not disfigure the body or change the way it looks. Nor does it cause any delay to funeral arrangements.

Provided they are suitable for donation at the time, I would like to donate the following organs:
[     ]  Kidneys          [     ]  Liver          [     ]  Heart/Lungs          [     ]  Pancreas          [     ]  All

SECTION 4: SIGNING AND WITNESSING
This form must be signed by you and by 2 witnesses. Both of these people must be over 18, and at least one of them must not be a member of your family and preferably should not be your attorney or patient-designated healthcare representative.


____________________
Your Signature

____________________
Witness 1 Signature

____________________
Witness 2 Signature

 


____________________
Date

____________________
Date

____________________
Date

Your wishes may change over time. For this reason we strongly encourage you to review this part of the form annually or as often as is appropriate for you. Please also remember that if you do make any changes to your Advance Healthcare Directive, these must be witnessed in the same way as the original.

This document preview is formatted to fit your mobile device. The formatting will change when printed or viewed on a desktop computer.
Loading ...
Loading ...

Note: Your initial answers are saved automatically when you preview your document.
This screen can be used to save additional copies of your answers.