ADVANCE DIRECTIVE
of ____________________

I, ____________________ (the "Donor"), of ______________________________________________________________, New Zealand, being of sound mind and at least 18 years of age, make this Advance Directive, fully understanding the consequences of my action in doing so. I intend this Advance Directive to be read by my health care providers, family, whanau and friends as a true reflection of my wishes and instructions should I lack Capacity and be unable to communicate such wishes and instructions.

1. Definitions
   
1. As used in this document:
   
   1. "Advanced Illness or Injury" means a severe illness or injury from which there exists no reasonable medical probability of regaining decision-making capacity or surviving without continued life support.
      
   2. "Capacity" means the ability to understand the nature of a decision about personal care and welfare, to appreciate the consequences of making or failing to make that decision, and to communication the decision.
      
   3. "Code" means the Code of Health and Disability Services Consumers' Rights.
      
   4. "Comfort care" means treatment, including prescription medication, provided to the patient for the sole purpose of alleviating pain and discomfort.
      
   5. "Health care provider" means any person licensed, certified or otherwise authorised by law to administer health care in the ordinary course of business or practice of a profession.
      
   6. "Life support" means any medical procedure, treatment or intervention which sustains, restores or supplants a spontaneous vital function. In this document the term does not include tube feeding or the provision of medication or the performance of a medical procedure when such medication or procedure is deemed necessary to provide comfort care or to alleviate pain.
      
   7. "Persistently unconscious" means being in a profound state of unconsciousness caused by disease, injury, poison or other means from which there exists no reasonable expectation of regaining consciousness.
      
   8. "Persistent vegetative state" means a permanent and irreversible condition in which there is:
      
      1. The absence of voluntary action or cognitive behaviour; and
         
      2. An inability to communicate or interact purposefully with the environment.
         
   9. "Terminal condition" means a condition caused by injury, disease or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death.
      
   10. "Tube feeding" means the provision of nutrients or fluids by a tube inserted in a vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).
       
2. Revoke Previous Advance Directive
   
2. I revoke any previous Advance Directive made by me.
   
3. In Force
   
3. This Advance Directive will be in effect only if and as long as I have been found to lack Capacity.
   
4. I give no one (including any Attorney appointed under a Power of Attorney for Personal Care and Welfare) any authority to disregard or override my instructions provided in this Advance Directive. Family members, relatives, friends may disagree with me, but any such disagreement does not diminish the strength or substance of my instructions.
   
5. Determination of Capacity
   
5. A determination of lack of Capacity will be made by my physician.
   
6. Notification on Determination of Incapacity
   
6. If a determination is made that I lack Capacity under the Code to make personal decisions on my own behalf then I instruct the person or persons making that determination to provide a written copy of that declaration to me.
   
7. Treatment Directions and End-Of-Life Decisions
   
7. I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
   
   1. If I have an incurable and irreversible terminal condition that will result in my death within a relatively short time, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   2. If I am diagnosed as persistently unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   3. If I am diagnosed as being in a persistent vegetative state and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   4. If I have an advanced illness or injury that is so severe that, to a reasonable degree of medical certainty, I will not regain decision-making capacity or survive without continued life support, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
8. Revocation
   
8. The authority granted in this Advance Directive may be revoked as and where permitted by law.
   
9. I understand that, as long as I have Capacity, I may revoke this Advance Directive at any time.
   
10. Statement of Values and Beliefs
    
10. ________________________________________________________________________________________________________________________.
    
11. Organ Donation
    
11. I do not want my organs or tissue to be used for transplantation upon my death.
    
    
12. General
    
12. A copy of this Advance Directive has the same effect as the original.
    
13. If any part or parts of this Advance Directive is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of that part or parts will not in any way affect the remaining parts and this document will be construed as though the invalid or illegal part or parts had never been included in this Advance Directive. But if the intent of this Advance Directive would be substantially changed by such construction, then it shall not be so construed.
    
14. This Advance Directive is intended to be governed by the laws of the country of New Zealand.
    

Signature

Signed by me under hand and seal in the presence of my witness in the country of New Zealand, this ________ day of ________________, ________.

Record of Copies
Record of people and institutions to whom I have given a copy of this Advance Directive: