ADVANCED DIRECTIVE
I _______(name) age _ years Indian, residing at ________ ___________________________ (address) hereby exercise my right to make decisions about my healthcare. This document titled “Advanced Directive” shall come into force when I am unable, due to my physical or mental incapacity, to make my own healthcare decisions. In the event of losing my capacity of decision making, those caring for me will need directions regarding my healthcare. By this document I express my wishes regarding my health care choices and direct my care givers; both healthcare workers as well as relatives and friends to take decisions in accordance to my expressed wishes hereunder.

1. I direct that this document become a part of my permanent medical record. I express that the instructions and wishes stated hereunder shall remain in full force and effect anywhere in the world.
2. I hereby designate my (relation) (name) _____age , as my healthcare representative to make any and all healthcare decisions on my behalf. This shall include decisions to accept or refuse treatment, service, procedure used for diagnosis or treatment for any physical or mental condition, provide, withhold, withdraw life sustaining measures. In case my wishes expressed are posing any challenge in interpretation, my healthcare representative is fully authorised to take decisions on my behalf.
3. If person designated as healthcare representative is unable, unavailable or unwilling, I designate following persons to act as my alternate health care representatives in following order of priority:
   a. ______________
   b. ______________
4. I direct that treatments that will artificially prolong my dying be withheld or discontinued in
   following circumstances:
   a. If I am diagnosed as having incurable, irreversible illness, diseases or condition and
   where by my physician determines that my condition is “terminal” in nature,
   b. If I become unconscious and there is a high likelihood that I may not recover back
   my consciousness.
   c. If I am diagnosed to have a disease that causes severe impairment of physical and
   mental functions such as dementia.
5. I direct that I be given treatment and care to make me comfortable and relieve my pain. I direct the physician to give necessary dose so as to provide maximum pain relief. I am aware that some of these medicines may lead to respiratory depression. I direct my physician to be undeterred of such side effects and provide pain relief of highest quality. I direct my healthcare representative to consent for the same, if need be.
6. When suffering from above conditions, in the event of cardiac or respiratory arrest, I direct not to initiate any resuscitation in any form on me.
7. I direct to provide supportive and palliative care and maintain my dignity till I die.
8. I direct my caregivers to interpret the above conditions with liberal meaning and not in
   restrictive manner.
9. I wish to donate my organs after my death. I have already completed formality regarding
   organ donation and I request to carry out organ donation procedure after my death.
10. I authorise my health care representative to keep original copy of this document.
11. I reserve my right to revoke this document by making fresh document after today’s day. The
    most recently signed document be considered as my final advanced directive in this regard.
12. I absolve the health care givers of any medico-legal liability which may arise during my
    treatment at that time. I direct my care healthcare representative not to initiate any action against any individual or organization for abiding by this document.
    I state that the above document has been made voluntarily by my free will and with sound mind and that I have understood the consequences of executing this document. I state that the same has not been made by me under coercion, inducement, misrepresentation or fraud. At the time of making this document, I am fully healthy and sane in mind and not under influence of alcohol, drug or substance.
    Executor:
    We, __________ age _ & __________ and age _ affix our
    signatures hereunder as witnesses. We confirm the executor’s identity as is of a sound mind while executing this document.
    Witness 1 Witness 2
    and further state that he

Instructions:

1. This is the draft of my living will. Every individual should add or delete what he/ she wants from this draft.
2. If you have any suggestions, please email them to me on drnikhil70@hotmail.com so that I could include them in the next draft.
3. Please type the matter yourself so that you will understand the meaning of each clause and you may be able to decide whether to keep the same clause or amend it.
4. You must execute the document in front of two witnesses who are independent.
5. This document should be attested before notary or gazetted officer.
6. You are supposed to send the copy of the document to the competent officer of the local
   government or municipal corporation or Panchayat.
7. This document has been made in accordance to the order delivered in the Miscellaneous
   application no 1699 of 2019 in writ petition (civil) no 215 of 2005 by Hon’ble Supreme court of India (https://indiankanoon.org/doc/55919876/)