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LIVING WILL

Advance Directive under Section 12 of the National Health Act B.E. 2550 (2007) of Thailand
Place of execution Date

PART 1PERSONAL DETAILS OF THE DECLARANT

I, (full name)Date of birth
NationalityThai ID Card No. / Passport No.
Contact address in Thailand
TelephoneE-mail
Regular healthcare facilityHN/CN
Healthcare coverage / health insurance

PART 2DECLARATION OF INTENT

I hereby make this declaration refusing medical treatment that serves only to prolong the process of my deceasing in the terminal stage of my life, or to end severe suffering from illness, in accordance with Section 12 of the National Health Act B.E. 2550 (2007) and the Ministerial Regulation Prescribing Rules and Procedures for Acting upon a Living Will Refusing Public Health Services Provided Merely to Prolong the Terminal Stage of Life or to End Severe Suffering from Illness B.E. 2553 (2010).

At the time of making this declaration, I am of sound mind, and I make it willfully and voluntarily, free from any duress, mistake or undue influence of any person. I request that my attending physician, medical practitioners and healthcare providers in any healthcare facility responsible for my care respect and act upon my wishes as stated in this Living Will.

I wish to die peacefully and naturally, without my death being hastened or prolonged to no benefit. Although I refuse certain medical treatment under this Living Will, I still wish to receive palliative care to relieve pain, suffering and discomfort according to my symptoms.

PART 3WHAT MATTERS MOST TO ME IN MY CARE (more than one may be selected)

(1) I want a good quality of life.
(2) I want treatment that does not cause pain or suffering, and that does not prolong my deceasing to no benefit.
(3) I want to live as long as possible, even if this means suffering from the use of medical equipment.
(4) Other (please specify)

PART 4CONDITIONS IN WHICH I DO NOT WISH TO REMAIN

Should I suffer any of the following conditions (those items marked with my signature), I regard such condition as the terminal stage of my life and I do not wish to remain in such a condition. Whether I am in such a condition shall be determined by my attending physician.

Condition
Signature
1. Permanent unconscious condition: A condition caused by illness or injury in which I become totally unaware of people or surroundings, do not recognise loved ones, am unable to make decisions, and have little chance of ever waking up from the unconscious condition (coma or persistent vegetative state).
2. Permanent confusion or dementia: I am unable to remember, understand or make any decision, I cannot recognise my loved ones or communicate with them meaningfully, and my condition is not expected to improve.
3. End-stage illness: I have an illness that has reached its final stage despite full medical treatment – for example, widespread cancer that no longer responds to treatment, or chronically diseased or damaged heart and lungs, where oxygen is required most of the time and physical activity is limited by a feeling of suffocation.
4. Fully dependent on life support: I am no longer able to breathe on my own and require continuous use of a breathing machine, IV fluids, or other medications or equipment that help the lungs, heart, kidneys and other vital organs to continue to function, but will not cure the underlying condition.
5. Permanent total dependency: I am bedridden and unable to carry out daily activities by myself, requiring constant care for eating, bathing, dressing and moving, and no treatment or rehabilitation can improve my condition.
6. Other (please specify)
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PART 5OVERALL SCOPE OF TREATMENT (select one only)

If I become seriously ill with very little chance of survival, or if I may survive but would deteriorate to the point of being unable to care for myself, I wish the scope of my treatment to be as follows:

(1) Full treatment, including life support, even if this causes me suffering from the use of medical equipment.
(2) Full treatment, including life support; however, if my attending physician considers it ineffective, I consent to the withdrawal of life support and to treatment of symptoms to prevent suffering, and I wish to die naturally.
(3) Treatment of symptoms to relieve suffering only, without life support or other life-prolonging treatment, and I wish to die naturally.
(4) I am not yet able to decide. My substitute decision-maker under Part 8 shall consult my attending physician, giving priority to my wishes as stated in this Living Will.
(5) Other (please specify)

If anything in this Part is inconsistent with the wishes I have signed item by item in Part 6, Part 6 shall prevail.

PART 6MEDICAL TREATMENT I DO OR DO NOT WANT

If I am in any condition stated in Part 4, or in the terminal stage of my life, or suffering from an incurable illness, and all treatment would only serve to delay the moment of my death or to prolong my suffering, I wish to be medically treated as follows: (Sign next to "Yes" if you want the treatment, or next to "No" if you do not want the treatment. Please sign only one box for each item.)

Medical treatment
Signature
1. Cardiopulmonary resuscitation (CPR). To cause the heartbeat to restart and to restore breathing after it has stopped. Usually this involves chest compressions, electric shock and breathing assistance.
YesNo
2. Intubation and life support. Endotracheal intubation, tracheostomy, continuous use of a breathing machine (mechanical ventilator), or other medications or equipment that help the lungs and heart to continue to function but do not cure the primary illness.
YesNo
3. Feeding tubes. The use of tubes to deliver food and water to the stomach, or other artificially delivered nutrition and hydration.
YesNo
4. Pain management. Use of pain medication in any form (intravenous, oral, transdermal patch) to relieve pain and suffering (for example, intravenous morphine for severe pain), including intravenous fluids as a route of pain medication delivery.
YesNo
5. Treatment of new complications. Use of surgery, blood transfusions, antibiotics or other treatments that deal with a new condition but will not relieve or cure the primary illness.
YesNo
6. Admission to an Intensive Care Unit (ICU). Transfer to an intensive care unit to support the function of vital organs.
YesNo
7. Dialysis or renal replacement therapy. Haemodialysis or peritoneal dialysis to replace the function of the kidneys.
YesNo
8. Other medical treatment. Any medications or procedures, such as antibiotics, chemotherapy or surgery, which will not cure my underlying condition but will prolong my suffering.
YesNo
9. Other (please specify)
YesNo

PART 7MY WISHES FOR THE FINAL STAGE OF LIFE

(1) I wish to spend the final stage of my life atHomeHospitalOther (specify)
(2) I wish to die atHomeHospitalOther (specify)
(3) Spiritual or religious care / rites I wish to receive
(4) Persons I wish to be with me or to be notified
(5) Other wishes

I kindly request healthcare professionals to accommodate the above wishes as appropriate and practicable.

PART 8SUBSTITUTE DECISION-MAKER

I appoint the following person as my substitute decision-maker, to explain my true wishes and to consult with the physicians and healthcare team caring for me in planning my care, when I am unconscious or unable to communicate normally, or when this Living Will is unclear. My wishes as stated in this Living Will shall always take priority.

8.1 Substitute decision-maker

Full nameDate of birth
Thai ID Card No. / Passport No.
Relationship to me
Contact address
TelephoneE-mail

8.2 Alternate substitute decision-maker (if the person in 8.1 cannot be reached or is unable to act)

Full nameDate of birth
Thai ID Card No. / Passport No.
Relationship to me
Contact address
TelephoneE-mail

This appointment is limited to decisions on my medical care under this Living Will. It is not a power of attorney to manage my property, bank accounts or any other legal transaction on my behalf.

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PART 9CUSTODY AND SHARING OF THIS LIVING WILL

9.1I authorise any healthcare facility holding this Living Will to keep a copy of it in my medical record and to send a copy to any healthcare facility treating me. No healthcare facility acts as my substitute decision-maker or representative under this Living Will.

9.2I have given copies of this Living Will to my substitute decision-maker and witnesses, so that they may present it to healthcare professionals when I am admitted to any healthcare facility.

PART 10CONSENT TO THE USE OF PERSONAL DATA

I explicitly consent to the healthcare professionals and healthcare facilities caring for me collecting, using, accessing and disclosing my personal data and health data under this Living Will, including through electronic systems, for the purpose of my medical treatment, and to transferring such data to other healthcare facilities for continuity of care. Healthcare facilities shall protect my personal data in accordance with medical confidentiality standards and the Personal Data Protection Act B.E. 2562 (2019).

PART 11WITHDRAWAL OF TREATMENT AND PROTECTION OF HEALTHCARE PROFESSIONALS

11.1Where medical treatment or procedures have been provided by any healthcare professional at any healthcare facility without knowledge of the contents of this Living Will or of my true wishes, I call upon such professionals to stop or withdraw the treatment and procedures I have refused in this Living Will.

11.2Physicians, nurses and other healthcare professionals who act upon my wishes as stated in this Living Will shall not be deemed to have committed an offence and shall be released from all liability, in accordance with Section 12 of the National Health Act B.E. 2550 (2007).

PART 12EARLIER LIVING WILLS AND CHANGES

12.1This Living Will revokes and replaces all living wills I have made before the date of this document.

12.2I understand that I may revoke or change this Living Will at any time. If there is more than one living will, the most recent one presented to healthcare professionals shall prevail.

12.3I have read and fully understood this Living Will and confirm that it correctly reflects my wishes. If I am unable to read English, its contents have been explained or translated to me and I fully understand them.

PATIENT DECLARATION

I, , hereby certify that, at the time of signing this Living Will, I am of sound mind and have decision-making capacity, I have been fully informed of my condition, prognosis and available treatment options, and I fully understand the consequences of this declaration. I voluntarily execute this Living Will by my signature or fingerprint.

SignatureDate
( ) Declarant

DECLARATION BY PHYSICIAN

I, Dr , Medical License No. , do hereby certify that, at the time of signing this Living Will, the Declarant (full name) is fully conscious, of sound mind and correctly oriented to person, time and place, has no mental or cognitive impairment affecting his or her decision-making, understands the nature and consequences of this Living Will, and has made it voluntarily, free from duress or undue influence.

SignatureDate
( ) Physician

SUBSTITUTE DECISION-MAKER

I agree to act as substitute decision-maker under Part 8 and will act in accordance with the wishes of the Declarant as stated in this Living Will.

SignatureDate
( ) Substitute Decision-Maker
SignatureDate
( ) Alternate Substitute Decision-Maker

WITNESS

Signature
( )
Relationship
ID / Passport No.
Date

WITNESS

Signature
( )
Relationship
ID / Passport No.
Date

NOTARY PUBLIC (Notarial Services Attorney)

I certify that the Declarant signed this Living Will in my presence.

Signature
( Kantee Isareenuruk )
License No.
Date

Notes

  1. Witnesses are optional. However, if the Declarant affixes a fingerprint instead of a signature, two witnesses must sign to certify the fingerprint.
  2. The Declarant should initial every page of this Living Will and attach a copy of the ID card or passport of the Declarant and of the substitute decision-maker(s).
  3. You may photograph or scan this document and upload it to create an electronic Living Will (e-Living Will) at https://elivingwill.nationalhealth.or.th/register
  4. To revoke or change this Living Will, please inform every healthcare facility holding a copy of the earlier version.
  5. This English version is a translation of the Thai version. In case of any discrepancy, the Thai version shall prevail.