Volume 1

Assisted Dying for the Terminally Ill Bill (HL) / Select Committee on the Assisted Dying for the Terminally Ill Bill.

  • Great Britain. Parliament. House of Lords. Select Committee on the Assisted Dying for the Terminally Ill Bill.
Date:
2005
Catalogue details

Licence: Open Government Licence

Credit: Assisted Dying for the Terminally Ill Bill (HL) / Select Committee on the Assisted Dying for the Terminally Ill Bill. Source: Wellcome Collection.

    114/152 (page 112)
    SCHEDULE Section 1 FORM OF DECLARATION Declaration made 202) Uy | rere eres eae ey Of (es Nusa ene “eae +a iF ; 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, Dr 5 has determined is a terminal illness and which has been confirmed by a consulting physician, Dr I have been fully informed of my diagnosis, prognosis, the process of being assisted 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. 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 this declaration. Signed: 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 proved his identity to me; (b) signed or made his mark confirming that this was his request in my presence; (c) appears to be of sound mind and to have made the declaration voluntarily; and (d) appears to understand the effect of the declaration.