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Patient (Assisted Dying) Bill [HL]


Patient (Assisted Dying) Bill [HL]

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 16    Short title and extent

     (1)    This Act may be cited as the Patient (Assisted Dying) Act 2003.

     (2)    This Act does not extend to Northern Ireland.

 

 

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Patient (Assisted Dying) Bill [HL]
Schedule — Form of declaration under the Patient (Assisted Dying) Act 2003

 

Schedule

Section 1

 

Form of declaration under the Patient (Assisted Dying) Act 2003

Declaration made ___________ 20__

[and re-executed ___________ 20__]

b y [____________________]

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o  f [____________________]

           I, ____________________, am an adult of sound mind who has been resident

in Great Britain for at least twelve months as at the date of this declaration.

           I am suffering from ____________________, which my attending physician

has determined is an irremediable condition and which has been confirmed

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by a consulting physician.

           I have been fully informed of my diagnosis, prognosis, the process and

probable outcome of being helped to die, and the alternatives, including

palliative care, care in a hospice and the control of pain.

           I request that my attending physician assist me to die.

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           I make this request voluntarily and without reservation.

           Please delete as appropriate:

           I have decided to inform / not to inform my family of my decision.

           I understand that I have the right to revoke the declaration at any time.

           Signed: ____________________

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           Date: ______________________

DECLARATION OF WITNESSES

           I declare that I am a solicitor with a current practising certificate and that the

patient signing this request:

              (a)             is personally known to me or has provided proof of his identity;

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              (b)             signed or made his mark confirming that this was his request in my

presence;

              (c)             appears to be of sound mind and has made the declaration

voluntarily; and

              (d)             understands the full force and effect of the declaration.

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           _________________________ Witness 1

           Date

           

 

 

Patient (Assisted Dying) Bill [HL]
Schedule — Form of declaration under the Patient (Assisted Dying) Act 2003

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           I declare that the person signing this request:

              (a)             is personally known to me or has provided proof of his identity;

              (b)             signed or made his mark confirming that this was his request in my

presence; and

              (c)             appears to be of sound mind and has made the declaration

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voluntarily.

           _________________________ Witness 2

           Date

           

           Notes

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          1.                                   One of the witnesses must be a solicitor with a current practising

certificate who has satisfied himself that the patient understands

the full force and effect of the declaration.

          2.                                   The patient and witnesses shall sign and witness the declaration

respectively at the same time and in each other’s presence.

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          3.                                   The attending or consulting physician, psychiatrist, or a relative or

partner (by blood, marriage or adoption) of the qualifying patient

signing this request may not be a witness.

          4.                                   No witness shall be entitled to any portion of the person’s estate

upon death.

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          5.                                   No person who owns, operates or is employed at a health care

establishment where the person is a patient or resident may be a

witness.

 

 

Patient (Assisted Dying) Bill [HL]
Schedule — Form of declaration under the Patient (Assisted Dying) Act 2003

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Revised 24 February 2003