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Living Will
(
to be filled in block letters: it is important that all the data are
clearly readable,
name, surname telephone number and signature of the
Person of Trust (FIDUCIARY) included. Dates must be handwritten.)
Name and Surname …………………………………………………………………………………………….
Place of birth………………………………………………………. COUNTRY …………..................
Date of birth…………………………………………………………………………………………………….
Permanent
place of residence
(street/area
code/city/Province State)
………………………………………………………………………………………………………………
Date…………
In possession of my full physical and mental faculties I state my Will as following:
In case I suffered from:
- a terminal disease
- an invalidating and irreversible disease or a cerebral traumatic lesion
- a
disease necessitating the permanent use of aiding machines or other
artificial systems
and preventing me from leading a life with
normal human relations,
I no longer want to receive any therapeutic treatment aiming to prolong my life.
In the situations mentioned above:
- if I suffer from severe pains I want to receive effective analgesic treatment even if this can shorten my life
- if I could no longer take food and liquids, I refuse to be submitted to artificial feeding and hydration
- if
I should suffer from any other intercurrent illness (such as
respiratory or urinary infections, bleeding, cardiac or renal
problems etc)
that could shorten my life, I refuse to be submitted
to any active treatment, in particular to antibiotics, blood
transfusions, cardiac resuscitation hemodialysis .
- I refuse any form of resuscitation and of prolongation of my life with the aid of machines.
Moreover I give the following dispositions.
° I wish religious assistance ( my confession is………… )
° I do NOT wish any religious assistance
° parts of my body can be donated for transplants
° NO part of my body can be donated for transplants
° my body can be used for scientific or didactic purposes
° my body CANNOT be used for scientific or didactic purposes
°
I wish to be cremated ( I am a member of the cremation society….
of……….
and
that my ashes are……………………)
° I do NOT wish to be cremated
° I wish my body to be buried (in the ground)
° I wish my body to be buried (in a tomb)
° I want to die in my home
° I want that my funeral be………………..
° I do NOT want any funeral
This Will has been consciously undersigned by me in the full possession of my mental powers and in the presence of the following witnesses:
WITNESSES ( name and surname. Write the names in block letters)
1……………………………………………………………………………………
2……………………………………………………………………………………
PERSON OF TRUST- FIDUCIARY (name, surname, address, tel. number)
who with their signature certify the truth of my declaration of will.
Signature: ..............................
Signature: ..............................
This
declaration of Will , provided I am still in possession of my full
mental faculties, can be modified by me at any time:
The persons
involved in the present procedure must be aware of this.
The
main aim of this document is to preserve the dignity of my person,
and to affirm my right to choose the medical treatments
I am proposed
and, if I so wish, to refuse some or all of them.
This right must be
guaranteed to me even if I had lost the faculty to express my opinion
about it.
This
in order to avoid treatments whose aim would be only to prolong my
life in an unconscious,
vegetative state and to delay an inevitable
death.
I
want that a copy of this Will be sent to the Association Exit-Italia
for the right to a dignified death,
seated in Turin Corso Monte cucco
144 (Italia) , association of which I am a member.
Signature of the testator (legible and handwritten)
………………………………………………………………
Special disposition
In case of interruption of the treatments did not cause my
death,
I ask that I be submitted to Euthanasia by the most suitable
method to procure me a dignified death without useless pain.
Date (handwritten)
…………………………………………………………………………………….
Signature of the testator (handwritten and legible)
…………………………………………………………………………………………..