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Disclaimer:Edit

☀This information is a work in progress and should not be interpreted as a 100% complete or 100% accurate guideline. Always take precaution and cross-reference information you can find elsewhere for your exact jurisdiction and situation.

☀This information is for general purposes and is not intended to direct or encourage anything, and is not intended to substitute individual legal advice. 

☀This information is a work of medical research and human rights activism. The goal here is to frame the most powerful, knowledgeable, up-to-date autonomy, risk-management, applied ethics "game theory" possible. This explores the concepts and frameworks for an "advance healthcare directive", based on maximum inclusion of scenarios. Example Prime focuses on elimination of prolonged suffering & prolonged impairment, at the sacrifice of the longevity of life. 

Topic SummaryEdit

An Advance Healthcare Directive, which guards your life and your autonomous decision of when to prolong life and/or when to shorten life.

It may include treatment you would refuse/consent to. You may modify this in any way that suits your healthcare agenda -- but always understand the meaning and implication of everything in your advance directive. This is a modern medical failsafe rooted in a wide spectrum of human rights, medicolegality, and other laws and ethics. It should stand tall against anything that would undermine it -- to be on the safe side, always confirm how your region's laws would correspond with all of this, IE. by web-searching examples of your jurisdiction's Advance Directive forms, your jurisdiction's legislation, your jurisdiction's POLST/GCD forms, or by consulting an attorney.

This document addresses the possibility of losing mental capacity, or sustaining severe, indefinite, long-term and/or permanent injury and/or impairment. An Advance Healthcare Directive remains in passive effect your whole life unless you explicitly terminate it (while having mental capacity). Its instructions are brought into active effect if you lose mental capacity.

This information is to remove the horror, uncertainty, fear, instability, contradiction, error, lack of insight, and violation of freedom from the dying process. This information is aggregated from across the world from almost a year of research. This effort was also motivated by the staggering lack of proper diligence in this domain as a whole. It was then set forth to make an Advance Healthcare Directive that was virtually immutable, inseverable and failsafe, and addressed every contingency (including the then-self/now-self problem, legal and ethical challenges, unknown unknowns, unanticipated events) - and this effort is concluded as Example Prime.

The byproduct of this is The Acceleration of Knowledge Evolution. Rather than being disintegrated across 100s of websites in insufficient explanatory framework, or stretched across 1000 book pages, this knowledge is just concisely built into 1 fortified wall on 1 website.

This wall is the fortification of global healthcare philosophy, autonomous rights and medical rights, the unification of citizens against those who would undermine those rights, and the frameworking of advance healthcare directives that can explore just about everything and are simultaneously effective in as many places/jurisdictions on Earth as possible.

There is crucial imperative for this. For example, at the time of this writing (March 22, 2019), even Wikipedia has a patently false and uncited entry claiming that "...in the United States... neither an advance directive nor a living will is a legally binding document." - and yet on this page it claims it "is a legal document" and "in the U.S. it has a legal status in itself". Disintegration of information is what undermines the unity of medical and autonomous rights. This has people living in suppressed-fear and conditioned-helplessness, and keeps the phenomenon of death far more grizzly and uncontrolled than necessary. To be fair, this page section has important cited information about the burdens and diminishing benefits of invasive and aggressive medical treatment.

Overall topic theme: 2019 Bioethics, Medical rights, Autonomous rights, and The Refusal or Consent to any treatment, intervention or encroachment on your person, for any reason at any moment, including for future scenarios. All this is accomplished by clarifying your determination, values, ethics, logic and philosophy in a legal-binding advance healthcare directive.

Short Term vs Long Term medical autonomy/personal autonomyEdit

Short termEdit

Do Not Resuscitate Confirmation Order (DNRCO)

This is for emergency healthcare, EMT, first responders, etc.

A Do Not Resuscitate Confirmation Order (DNRCO) is acquired by going to a medical practitioner and getting one made, signed, and initiated by usually a doctor.  

A DNRCO is a legal-binding document, wristband, and/or necklace. They exist for individuals who do not want CPR or life-prolonging intervention enacted on them by emergency services. DNRCOs are often worn on your body or kept in your wallet, because many jurisdictions do not have a central database for EMT to access this information (which is a failure of society to maintain modernized and transparent protocol for medical refusal and consent). Note that EMT / first-responders do not necessarily seek or obey Advance Directives, so beware if your Advance Healthcare has a DNR for when your breathing/heart stops, but you have not acquired a DNRCO that is readily available to block emergency services from attempting to resuscitate you. 

Long termEdit

Advance Directive / Advance Healthcare Directive

This is for public care, private care, medical care, prison care, psychiatric care, end-of-life healthcare.

An Advance Directive is a legally-binding document that dictates your medical and autonomous rights of refusal and consent. An individual writes, prints out, or fills-in a template for this document and outlines their healthcare values with it, then signs it in front of proper witnesses/notaries who verify the maker's identity and capacity/soundness of mind, then photocopies are made of the completed form. The original is wisely kept on your person when you travel, or in your house where it is easily found (IE. laminated on the fridge).  

Photocopies should be made and distributed to go on your medical record, with your doctor, friends, family, and everywhere else you want to distribute it. Your Advance Directive concerns both your medical rights and autonomous human rights, to refuse/consent to any form of intervention on your person, for any reason and at any point in time, for both private and public care. 

Glossary and ConceptsEdit

The following terms are key concepts that have been legally and logically established. They can be used for construction of your advance directive. They expand and explore crucial options for personal autonomy, healthcare planning and informed consent.

DNR (Do Not Resuscitate)Edit

This can be stated as a catch-all for all circumstances, or specified toward denial of being resuscitated in certain circumstances/states of life, or being resuscitated if your breathing stops vs if your heart stops.

DNH (Do Not Hospitalize) Edit

A Do Not Hospitalize order typically isn’t an absolute direction not to hospitalize under any circumstance – though it could be. It’s usually nuanced, aiming to reduce hospitalizations rather than prohibit them outright. 

To quantify the prevalence of DNH orders, Taeko Nakashima, PhD, and colleagues examined a population of more than 43,000 nursing home residents in New York. Overall, 61% had do-not-resuscitate orders, 12% had feeding restrictions, and only 6% had DNH orders, according to results published in the May 2017 Journal of Post-Acute and Long-Term Care Medicine. (Citation: https://www.ncbi.nlm.nih.gov/pubmed/28214236 - Archived version: https://web.archive.org/web/20190326024406/https://www.ncbi.nlm.nih.gov/pubmed/28214236

DNT (Do-Not-Transfuse) Edit

This order is written when an individual has declined blood transfusions and/or the use of other specific blood products because the use of transfusions will not meet his or her health care goals.

DND (Do-Not-Dialyze) Edit

This is a written order confirming that an individual or his or her duly appointed representative has declined the use of kidney dialysis (in situations of kidney failure coupled with other permanent poor health).                  

DNI (Do Not Intubate)Edit

This can be stated as a catch-all for all circumstances, or specified toward denial of being intubated, injected, or transfused for Blood, Oxygen, Antibacterial agents, antiarrhythmics, Drugs, Hydration and/or Nutrition.

Refusal of Artificial and Tubefed Nutrition and HydrationEdit

This can be stated as a catch all for all circumstances, or specified toward denial of any combination of artificial/tubefed hydration or nutrition, and specified toward refusal of Articial/Tubefed Hydration and Nutrition in certain circumstances/states of life.

Refusal of Life-Sustaining Intervention Edit

A legal right to refuse medical treatment, even if that treatment is necessary to sustain life. This can be stated as a refusal of all life-sustaining intervention and treatment, or specified toward various life-sustaining measures for various circumstances. These life sustaining interventions can include ventilators, feeding tubes, pacemakers, surgery, antibiotics, blood transfusions, antiarrythmics, dialysis, etc.

AND (Allow Natural Death)Edit

This can be stated as a catch-all for all circumstances, or specified toward allowing your natural death to happen in the case of certain intolerable circumstances/states of life.

Total Palliative SedationEdit

Palliative/total sedation – Also referred to as terminal sedation. This can be included in any Allow Natural Death plan. This entails the continuous administration of medication to relieve severe, intractable symptoms that cannot be controlled while keeping the person conscious. This state is maintained until death occurs.

MAID (Medical Aid In Dying)Edit

This is a rare but effective option legally. Leading medical organizations reject the term “physician-assisted suicide”, and establish that "medical aid in dying" and "the voluntary/calculated/rational measure to end your life" is fundamentally distinct from the colloquial and demonized term "suicide". Because of just how loaded the term "suicide" is, because of how dangerously uncertain that an unmoderated impromptu suicide is, and how the normative idea of "suicide and the desire to end your life" is erroneously denoted and/or treated as being fundamentally irrational, when all this is just the opposite.

Unfortunate insurance exclusions are triggered by suicide and tragically bad outcomes can be caused by failed suicide attempts. There is some sense that condoning medically induced death will avoid the undesirable consequences of self-inflicted suicide, at least for those patients who are qualified under the Initiative. Citation: "The Community Ethics Committee", created under the auspices of the Harvard Ethics Leadership Group and functions as a part of the nonprofit, Community Voices in Medical Ethics, Inc. https://drive.google.com/file/d/0B-ehSSMbV_I6Rjh1U000YmlTR3M/view Archived version: https://web.archive.org/web/20190318232510/https://drive.google.com/file/d/0B-ehSSMbV_I6Rjh1U000YmlTR3M/view

There is a distinction between MAID and Euthanasia, MAID is fundamentally different from Euthanasia in the following regard: While both practices are designed to bring about a peaceful and voluntary death, the distinction is who administers the means to that peaceful death. Euthanasia is an intentional act by which another person (not the dying person) administers the medication. By contrast, medical aid in dying requires the patient to be able to take the medication themselves and therefore always remain in control (which crucially means that MAID is not available to patients who are severely incapacitated or incapacitated to the point of unconsciousness or inability to self-administer). Euthanasia is illegal throughout the United States, but MAID is authorized in six states plus Washington, D.C., with legislation being considered in 26 other states. Citation: https://compassionandchoices.org/resource/assisted-suicide/ Archived version: https://web.archive.org/web/20190117185505/https://compassionandchoices.org/resource/assisted-suicide/

At present, physician‐assisted suicide, also known as aid in dying/MAID, is legal by "judicial decision" in Montana, and by "statute" in six other U.S. jurisdictions, Oregon, Washington, Vermont, Colorado, California, and the District of Columbia; come January 2019, it will be legal by statute in Hawaii as well. Medical assistance in dying (MAID) is also legal in Canada following a Canadian Supreme Court decision and subsequent implementation legislation. Citation: https://onlinelibrary.wiley.com/doi/10.1002/hast.919 Authors: Bonnie Steinbock Paul T. Menzel, PHD. First published: 11 October 2018

MAID requires a lot of criteria and evaluation before it is permitted, and is hard to specify in advance. But it can theoretically be requested in an advance directive, with the caveat that "if it is legally an option in a specific or range of intolerable circumstance(s)".

EuthanasiaEdit

This is perhaps the most rare option legally, banned in almost all countries on earth, and is often treated as the infamous stalemate for the right to die. However, as indicated by this glossary of concepts, Euthanasia is far from the only option regarding autonomous rights to choose when to allow one's death. The next concept (VSED) is the most powerful of all these concepts, in the sense that it may work even if you are incapacitated, even if MAID is unavailable, even if Euthanasia is unavailable, and even if your life is not being prolonged by any sort of medical intervention, or assisted intervention that DNR/DNI/AND would refuse.

VSED (Voluntary Stopping of Eating and Drinking)Edit

VSED offers patients “a way to escape agonizing, incurable conditions that they consider to be worse than death.” (145)  A death incident to VSED is peaceful, relatively painless, and dignified. (146) Many people choose this option so that they may be in control of their own deaths, knowing that they will be dignified deaths.(147) Furthermore, many people benefit not only from using this option, but also from the mere knowledge that it is available. https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

VSED can be explicitly stated as the denial of all hydration and nutrition, or specified toward denial of either hydration or nutrition. VSED can be specified toward certain circumstances/states of life, or a wide range of general ones.

VSED can even be initiated in prison systems. (See citations 176, 273, 309, 323, 324, 330 of https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

Despite resulting in death, VSED is technically not suicide: neither logically, conceptually, or legally as that term is used in prohibitions of assisted suicide and prohibitions of suicide. Simply put: Starving and dehydrating is not suicide, so failing to prevent it is not assisted-suicide or suicide. Suicide prohibitions are targeted at active interventions, such as the introduction of a lethal agent. VSED, in contrast, entails only a passive refusal. One's natural state is to dehydrate/starve unless fluids & nutrients are affirmatively introduced. Such a process cannot be tantamount to suicide, and VSED does not entail the acceleration of this process, but rather the mere absence of action to slow or stop it. (See citations 387-405 of https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

If someone were to contrast the non-suicide argument of VSED, by suggesting it would analogously be non-murder to deprive someone of food or hydration in a quasi-VSED scenario, the "forcibly" part of that equation will always nullify that argument and analogy. VSED is "voluntary stopping", not "forcibly stopping". The multitude of provisions against kidnapping, criminal neglect, and common-law infringement on personal autonomy, ensures it is criminal to both interrupt someone's VSED and to force someone to VSED. So rest assured there are no such quandaries or rifts of loopholes or contradictions with VSED. (See citations 29, 90, 280-310 of https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

In short, while failing to provide adequate nutrition and hydration can constitute abuse and neglect, it constitutes neither when the patient specifically consented. (375). While federal and state laws are aimed at protecting vulnerable individuals, these same laws place an even higher priority on honoring patient autonomy. (376). The regulations were never meant to override the right to refuse. (377)

While the physician need not honor a request for affirmative assistance (“making [the] patient die”), the physician must honor the patient’s refusal (“letting [the] patient die”). (398) Unlike a demand for Physician Assisted Suicide, a demand for VSED is grounded “on well-established traditional rights to bodily integrity and freedom from unwanted touching.” (399) Force-feeding is undoubtedly offensive to the VSED patient, since it deprives the person of dignity and autonomy in the decision to stop eating and drinking. Indeed, force-feeding is not a dignified act. (299) 

Also, while force-feeding is not always necessary because the person cooperates with being fed and hydrated, such "cooperation" is often achieved through coercion and duress. For example, when Elizabeth Bouvia—a quadriplegic who wished to VSED—refused to eat, (301) providers threatened her with a loss of smoking privileges and morphine unless she ate. (302) Such consent does not change the fact that the unwanted touching is a battery, the mind of the VSED patient was not changed through re-consideration, or discussion of the rationale for VSED, but through coercion and manipulation from her providers leveraging nicotine and morphine. “Consent is not effective if it is given under duress.” (303)

Additionally, placing food near the VSED patient can be a battery. VSED requires significant amount of will power and support to maintain the decision. (305) If food is placed in front of a person, sights and smells cause chemical reactions in the body that make the person salivate and feel hungry. (306) This in fact chemically-undermines the decision to VSED because it coerces the person to waver in his or her decision. (307) Battery is established not only by contact with the person herself but also with an object connected to (or intimately associated with) the person. For example, touching the hat someone was wearing, or the umbrella they were using would be enough contact for common law battery. (308) Similarly, invading a person's space or placing food on a person’s bed, or on a table attached to their bed, would constitute a battery when the VSED patient made it clear to get out of their personal space and stop tampering with their items. The touching covered by battery is broad. The contact does not have to be direct person-to-person contact. The tortfeasor can touch something that is connected to or intimately associated with a person’s body, like a cane or a plate. (288) Similarly, the tortfeasor himself does not have to contact the person, but rather, the tortfeasor can cause an object to touch the person. This could be in the form of something as simple as throwing a tennis ball at a person, or as intangible and amorphous as a cloud of smoke contacting a person. (289) https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

Palliative and sedated VSED also exists (both naturally-induced & medically-induced) which can possibly make the process anywhere from relatively to nearly painless.

At the twenty-four to forty-eight hour mark, when the body has exhausted its carbohydrate stores, it begins to metabolize muscle tissue. 229 Although this process sounds painful, it actually often has the opposite effect. When the body metabolizes muscle, molecules classified as ketones are released into the bloodstream, sending the body into a phase called ketosis or ketonemia. 230 Ketosis causes many people to enter a state of euphoria. 231 It has also been credited with impairing hunger, relieving pain, and increasing the quality of life for the dying person. 232

(232. See M ERCK M ANUAL , supra note 93, at 2766; Byock, supra note 160, at 9.) Voluntarily stopping eating and drinking is a flexible process that allows people to be in control of their own death. It is recommended, however, that people who choose VSED quit eating and drinking cold-turkey because taking in small amounts of food and drink prevents ketosis and prohibits the euphoric and analgesic effects of the onset of ketosis. See infra note 274.

For example, a questionnaire was mailed to all nurses employed by hospice programs in Oregon. Of the 429 eligible nurses, 307 (72 percent) returned the questionnaire, and 102 of the respondents (33 percent) reported that in the previous four years they had cared for a patient who deliberately hastened death by voluntary refusal of food and fluids. On a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of these deaths, as rated by the nurses, was 8. See citation: https://www.nejm.org/doi/full/10.1056/NEJMsa035086 (Archived version: https://archive.fo/0xXX6 )

[T]he feeling of hunger often disappears in 2-4 days, provided the person drinks water only.”). Molrine, supra note 213, at 5 (stating that “feeding even small amounts can prevent ketonemia and prolong the sense of hunger . . . . Indeed hunger rapidly reappears when ketosis is relieved by ingesting small amounts of carbohydrate . . .”)

Some hospices use a dry sponge dipped in the patient’s favorite liquid. But this is inappropriate because the liquid is aqueous. See infra Part III.D (death by “bad” dehydration). It is preferable to use a non-aqueous organic base such as glycerin or sprays with methyl cellulose. See supra note 248.

(; F RIENDS AT THE E ND , supra note 25, at 9-10) (describing, in addition to recommending nose, eye, and face care, four methods of mouth care: (1) refreshing the mouth; (2) saliva stimulating products; (3) saliva substitutes; and (4) cleansing to prevent fungal infection); T ERMAN , supra note 75, at 102-05 (describing comfort care for those who refuse food and fluid); Cantor & Thomas, supra note 27, at 95; Molrine, supra note 213, at 5.

Given all of its utility, given its feasibility to solve every single legal, conceptual, logical and ethical blockade in the right to die, VSED is arguably the most powerful option in the world for allowing one's death: maintaining utility even when all other options fail. If one's intolerable suffering is not being prolonged by resuscitation, intubation, or any life-sustaining intervention, yet nevertheless one determines one's life to be intolerable. VSED can be used as a current/contemporaneous option, and/or a planned-in-advance option. VSED can be stated as a catch-all for all possible forms of Natural, Artificial, Spoonfed, Tubefed, Handfed, Oral, and/or Assisted Nutrition/Hydration - or specific forms of it. Courts have misinterpreted VSED as only a denial of "Artifical and Intubated hydration/nutrition" in the past, due to unclear wording and not establishing the phenomenon of VSED. This can be solved by using as many adjectives as possible to make VSED explicit, and to include citations and website links inside your advance directive to prove beyond all doubt what the phenomenon of VSED is, and that you know what it is and have studied it, and that you dictate it to be your autonomous decision and plan. Another way of guaranteeing VSED is followed is by explicitly stating the purpose of VSED is to hasten your own natural death via VSED. There can also be an explicitly stated contingency for VSED if it is meant to apply even if you appear to being consent to being fed/hydrated - IE by opening your mouth or forgetting your VSED objective - which is known to happen in states of brain damage and dementia and delirium. One can also include and explain a "palliative contingency plan", if your incapacitated-self ever attempts to override/undermine VSED. This can be accomplished by establishing that you want caretakers to primarily offer palliative support in the case that you ask for food/water. This is an ethical game theory and failsafe intended to cure the sensation or pains of thirst/hunger, without actually hydrating or nourishing. This offers a safeguard both to VSED and to possible pain/discomfort - so only in the unlikely case that palliative measures fail or wind up futile, and your pain winds up intolerable, will VSED be suspended until the situation can be taken back under control. VSED palliative support includes: humidifiers, mist sprays, medical swabs, palliative drugs, palliative injections, palliative suppositories, total deep-sleep palliative sedation, and more. VSED is not necessarily fool-proof or failsafe: nor is anything in life. However, by taking all these measures into account, and by making this phenomenon loud and clear to everyone in your life, VSED can be the #1 theoretically, plausibly, and practically guaranteed way to ensure that this is all in excellent order. To ensure your right to die is not violated, and that your life is not, by any means, maintained far past the point of what you autonomously dictate to be intolerable state(s) of being.

VSED Citation 1: Thaddeus Mason Pope (leading bioethicist, Professor of law, PhD, and JD) gives state-of-the-art legal and medical expertise for VSED and how to enact VSED in a dignified, legal, ethical, peaceful, controlled, palliative and sedated manner. In the following citation, he explores how this is accomplished, in the most comprehensive paper ever published on VSED (containing over 400 citations): https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch Archived version: https://web.archive.org/web/20190318205703/https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

VSED Citation 2: A successfully accomplished VSED, for an Alzheimer's patient who refused to decay into dementia. A comprehensive documentation of the process, medical tools, legal papers, and logistics. (Note the patient in question did not want total palliative sedation, he wanted to remain conscious enough to savor the remainder of time with his wife, which lead to occasional but manageable forms of stress and discomfort): https://www.phyllisshacter.com/the-vsed-choice/medical-preparations/ Archived version: https://web.archive.org/web/20170506001908/http://www.phyllisshacter.com/the-vsed-choice/medical-preparations/

VSED Citation 3: In “Avoiding Deep Dementia,” legal scholar Norman L. Cantor explains why he has an advance directive that calls for voluntary stopping of eating and drinking as a means of ending his life if he develops dementia and reaches a particular state of decline. Cantor’s essay and three accompanying commentaries bring up many important points. https://onlinelibrary.wiley.com/doi/full/10.1002/hast.865 Archived version: https://web.archive.org/web/20190318220509/https://onlinelibrary.wiley.com/doi/full/10.1002/hast.865

Norman L. Cantor (Professor of Law Emeritus and Nathan Jacobs Scholar Emeritus at Rutgers University School of Law, Newark.) Norman L. Cantor has been widely published in legal and medical journals on the topic of the legal handling of dying medical patients and has 3 prior books in that field.

Citation: Norman L. Cantor: My Revised Advance Directive: http://blog.petrieflom.law.harvard.edu/2017/04/20/changing-the-paradigm-of-advance-directives/#_ednref8

Archived version: https://web.archive.org/web/20190127122933/http://blog.petrieflom.law.harvard.edu/2017/04/20/changing-the-paradigm-of-advance-directives/

VSED Citation 4: There are also entire organizations like Hemlock Society, End of Life Washington, and Compassion And Choices that support this:

- https://compassionandchoices.org/end-of-life-planning/learn/vsed/

- https://endoflifewa.org/wp-content/uploads/2014/01/VSED.Packet.10.2015.pdf

- https://www.hemlocksocietysandiego.org/eol.htm https://www.youtube.com/watch?v=lGrug7HKCEI

- https://endoflifechoicesny.org/wp-content/uploads/2017/11/Alzheimer-s-Disease-and-Written-Directives-to-Withhold-Oral-Feedings-1.pdf (by Judith Schwarz,

RN, PhD, and Consultant of end of life choices, New York)

VSED Citation 5: Professor Thaddeus Mason Pope's website with key resources:

http://www.thaddeuspope.com/hasteneddeath/vsed.html

Archived version: https://web.archive.org/web/20180105075930/http://www.thaddeuspope.com/hasteneddeath/vsed.html

Advance Directive "Armor" Edit

There are a multitude of ways to armor, solidify, protect, supplement, and strengthen your Advance Directive and medical/autonomous rights. This failsafing and security process involves:

(Required): Witnesses / Signatory / Notary / Declaration of mental capacity / FormalizationEdit

This sounds complicated, but can be reduced to this simple distinct procedure:

1. Witnesses and notaries: Having 2 witness and 1 notary makes Advance Directives effective in virtually every region on earth that has them. (Check your exact region's requirements to be sure.) E.g. Witness requirements in all 50 states of America

2. Witness and notaries requirements: Must be adult age/legally required age (check your jurisdiction's age requirements). For maximal legal efficacy, witnesses should be non-blood-related, not related by marriage or similar common-law partnership, not entitled to any portion of your estate, not a person who has a claim against your estate, not healthcare affiliated (not your attending physician, not an employee of your attending physician, not an owner, operator, administrator, or employee of a health care facility in which you are a patient at the time you sign your instructions). This is all anti-conflict-of-interest to ensure utmost quality and indisputability of the witnesses and of your plan.

3. Witness and notaries preparations: Ensure that all signatories to the document(s) will be present at your appointment and can produce a valid, government-issued, photo ID. Do not sign and date your Instructions until you are in the presence of valid witnesses, and a notary, if you are having your Instructions notarized. Notaries can be found at your bank, insurance office, or some office supply stores (call ahead to make sure they will be present).

4. Witnesses and notaries: Example of what "official and solemn declaration" looks like for each:

A:

Witnesses declaration:

The Maker of this advance directive is personally known to us or has provided proof of identity, and we hereby verify this advance directive was made with the Maker's informed, deliberated, calculated, self-determined, and full mental capacity.

______________________________ ______________________________

Witness #1 Signature + Date Witness #2 Signature + Date

B:

Notary declaration:

On this ____day of _______________, 20___ in the City/Town of_________________ in the state/province of _________________, personally appeared before me the aforesaid declarant and principal, to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. 

___________________________________ Notary Stamp:

Signature/position of Notary Public

____________________________________

My commission expires (date)

5. If your Advance Directive applies even if your death is at risk as a result, be sure to state this, regions like England require this as standard protocol. EG. "Even if my life is at risk & my death is hastened as a result of this treatment/plan."

6. Check Advance Directive age requirements for your jurisdiction.

7. Recommended as a best practice that you and the witnesses *initial* each page of the document as well. This guards against somebody swapping out pages.

8. Void all previous Advance Directives made by you (unless you want previous Advance Directives to remain active alongside your new one(s)).

Backups and Immediate Retrieval

Due to the disintegration of information and people being unaware of their autonomous and medical rights, there is also a widespread absence of State Registries or Central Registries for advance healthcare directives, which causes even more disintegration. There exists ample technology to have everybody's advance directive backed up, remotely and immediately retrievable by the healthcare system, instead of sitting on a piece of paper where it can just be ignored, yet most places fail to make these registries and solve this. Citation: Thaddeus Pope - 2018 ACP Michigan Conference https://vimeo.com/306403553 ((3 minute 48 second mark - in the most systematic review this legal scholar could find, a review that looked at 150 other studies which altogether used 800,000 subjects, the advance directive completion rate is 37%) (4 minute 50 second mark, 76% of physicians whose patience have advance directives do not know they exist) (5 minute 52 second mark, finding that only 1/3 completed advance directives were actually put into action when needed, Senator Jim Marleau made an advance directive registry for Michigan) (47 minute 30 second mark, there were bills for ADs not passed in U.S., e.g. paying every adult $75 to complete an Advance Directive)

1. Documents can also be photographed and kept on smartphones, computers, etc. Your advance healthcare directive may be photographed or captured with a video and stored (with dated records included) on digital device(s) - or - digitally-scanned after completion and re-saved onto a device as a digital file (such as .pdf, .odt, .docx). After advance directives are digitized, they should always be securely hashed by a program that supports secure hash algorithms such as "SHA" (which is something even federal governments use to verify and secure their data). This gives you a "checksum" for the digital advance directive to prevent file tampering (more info on this here).

2. Documents can be accompanied with a video, which showcases you and the document clearly spelled out and visible, with you visibly and audibly acknowledging & explaining your rationale and values. This adds an entire dimension of psycho-social assurance and humanizes/personalizes everything about it, which eliminates ambiguity, doubt, and misinterpretation to almost nill. This video might even forgo the very chance of "contesting the validity of witnesses, signatures, or contesting the validity of your identity", since that's technically only a problem manifested from "written word documentation" to confirm it was actually you who wrote it, video proof eliminates that problem.

3. Wallet cards or notes attached to your driver's license, which leave no doubt you have an advance directive dictating your autonomous and medical consent/refusal that must be followed, indicating where it can be found and who has copies of it. Additionally, the internet can be used for backups and immediacy of retrieval. This would be a system whereby you make your advance healthcare directive and video explaining it's "securely hashed" and "stored publicly/privately online or on offline digital devices", then the hash values (checksums) and hyperlinks can be put/lamented on a card - the hash proves the authenticity of the file, the hyperlink directs healthcare personnel to the file. (It's even possible to have a QR coded card that links to a video version of your advance directive values, so it can be retrieved and viewed in emergency by the medical workers who would be strangers to you and unaware of your Advance Healthcare Directive - however this is a new and state of the art phenomenon. Read more about "Mideo" advance directive cards:

https://institutehcd.com/

https://www.erienewsnow.com/story/39593675/mideo-health-card-software-technology-platform-launches

https://mideocard.com/

Range of applicationEdit

A: The places on earth your autonomous/medical game theory will apply in ("where" you are living, with regard to jurisdiction and legal medical options). This is known as "portability" or making your advance directive plan "portable across jurisdictions".

B: The states of health your autonomous/medical game theory will address ("how" you are living, with regard to your neurological and biological capacity, status and function).

C: The circumstances of environment your autonomous/medical game theory will apply in ("where" you are living, with regard to public and private care, what "types" of care facilities/places you consent -or- refuse to be admitted to).

PortabilityEdit

The portability of your advance directive plan (to make it effective in as many places at once as possible). This coincidentally includes securing your plan in a multi-dimensional legal/medical/constitutional framework, so that basically:

Using a Common Law basis for your refusal and consent - basing your advance directive on not just your state rights, medical rights, or state medical rights - but also your constitutional, autonomous, and common-law rights that exist, not only for the entire region of your country, but the entire region of many other countries. Basically, you have constitutional and common-law rights to consent to or refuse treatment/intervention that may be even broader than your rights under any state's law. This is explained much more in detail in Thaddeus Mason Pope's VSED paper, specifically rooted in common-law battery and unwanted intervention on your person: https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

A state would therefore be legally obligated to honor an advance directive that clearly expressed your treatment wishes, even if the state's medical jurisprudence had grey areas or disagreeable areas toward your directive and plan, because your plan is not just founded in state law. This is especially the case if your lawyer, healthcare proxy, power of attorney, family representative, public trustee, ethics committee, or any other lawyer/representative was made aware of this entire game theory, and expounded all of this in court (in the event that anyone ever tried to challenge your refusal and consent rights). And if your case additionally was tracked by the community involved in establishing all of this: united we stand.

Citation: https://www.afscme.org/news/publications/life-management-and-health/questions-answers-on-advance-directives-for-end-of-life-medical-treatment/advance-directives-what-they-are-and-what-they-do

Archived version: https://web.archive.org/web/20190114163926/https://www.afscme.org/news/publications/life-management-and-health/questions-answers-on-advance-directives-for-end-of-life-medical-treatment/advance-directives-what-they-are-and-what-they-do

POLST and GCDEdit

POLST (United States) or GCD (Canada) or your country's equivalent if available, is a separate type of document very similar to advance directives. It is highly useful for establishing refusal and consent rights, in that in triple-downs on your plan:

IE. because POLST is integrated across at least 40 States in the U.S. which gives it (and your plan) inherent portability, even though that's already taken care of if you additionally base your advance directive in common-law battery/autonomous rights/constitutional rights.

IE. because it ensures your advance directive is codified twice-over to eliminate ambiguity/misinterpretation of the plan, and

IE. because it ensures extra awareness of your advance directive and healthcare planning, which drastically reduces the chance of your plan not being followed on the grounds that people were not aware of your plan.

Think of these terms/forms as the shadows of Advance Directives. They are integrated on the side of the medical institutions and medical personnel (even though photocopies of your advance directives can and should be integrated into their system and possession regardless). Physician Orders for Life Sustaining Treatment — ACP is most effective when it is part of a coordinated effort that can be used across the continuity of possible care settings by paramedics, in hospitals, and in residential care facilities, such as nursing homes. A model initiative for such a directive is the Physician Orders for Life Sustaining Treatment (POLST), which delineates what specific care should be administered or withheld at the present time for a specific patient, as directed by a physician. Because these are considered medical orders, signed by a physician, they are “portable” in states where POLST programs have been legislatively established (40 states as of October 2016) [49]. This means that where they can be applied, all health care facilities and emergency service providers in the region have agreed to recognize and abide by them, regardless of where it was first signed. POLST is particularly relevant to patients expected to transition from one health care setting to another. International jurisdictions, such as in some states in Australia and Canada, have also developed similar approaches, although the names of the documentation vary and include “Goals of Care” (GCD) and “resuscitation orders.” Citation: https://www.uptodate.com/contents/advance-care-planning-and-advance-directives Archived version: https://web.archive.org/web/20171226180923/http://www.uptodate.com/contents/advance-care-planning-and-advance-directives Authors: Karen Detering, MD. & Maria J Silveira, MD, MA, MPH

Medical ProxiesEdit

Medical proxies - also known as Proxies, Powers of Attorney for Healthcare, Durable Power of Attorney for Health Care (DPAHC), Health Care Proxy, or Health Care Power of Attorney - is signed legal documentation authorizing another person to make medical decisions on the patient’s behalf in the event the patient loses decisional capacity. The application of DPAHCs began when it was recognized that Living Wills were limited in terms of the range of decisions they could cover. States began sanctioning DPAHCs in the 1980s and 1990s, and every state in the United States has a health care proxy statute as part of state law. Like the Living Will, a state-specific DPAHC reduces the likelihood that a third party can challenge the patient’s choice of surrogate.

However, there is no legal requirement that an individual choose a surrogate; in most jurisdictions, there is specific legislation authorizing which person can make decisions in the absence of a formal designation. Nevertheless, selecting a surrogate helps clarify who the patient’s preferred surrogate would be. Ideally, the process of choosing a surrogate would be the occasion for discussions with that person about preferences for care in the event of an incapacitating, severe illness.

Citation: https://www.uptodate.com/contents/advance-care-planning-and-advance-directives

Archived version: https://web.archive.org/web/20171226180923/http://www.uptodate.com/contents/advance-care-planning-and-advance-directives

Authors: Karen Detering, MD. & Maria J Silveira, MD, MA, MPH

Death doulas and death midwivesEdit

These terms basically mean the people who are watching over you during your decidedly and foregone dying process (especially for VSED/MAID/AND/etc.) - and who are moderating the process. https://en.wikipedia.org/wiki/Death_midwife

Release and Assumption of RiskEdit

Release and assumption of risk forms (or clauses in your advance directive) to remove caretaker liability of your death, in the case that you are voluntarily choosing to allow your death. This is a powerful legal game theory, meant to legally guarantee the process is copacetic to everyone involved. It is meant to free everyone of background doubts or fear, and to remove the "legal volatility" of the right to die. This is done by explicitly acknowledging you are aware of (and you consent to) the death risk, that you have ascertained and calculated this decision with your sole discretion, rooted in your ethical philosophy and long-term deliberate rational judgement, and carried out by solely your command, and you are not holding anybody else liable for your death. (Writing this explicitly would be highly advantageous.)

Digital Backups - When All Else FailsEdit

This is a theory for creating a secure digital copy of an Advance Healthcare Directive, if you are in an usual predicament: If there is lack of state registries, lack of stable medical registries, lack of immediately accessible backups if you are traveling, and if you currently have no one else to vouch for you, or if you want the most bonus backup security possible. Before applying a digital Advance Directive, it would have to be hashed/checksumed to check if it was tampered with.

1. First take a photo, video, or digital-scan of your document after it is 100% witnessed, dated, signed, notarized, filled-in, completed

2. Save the photo/video/scanned document version to a computer as a digital file

3. Load the digital file into a hash/checksum program (that supports secure hash algorithms such as "SHA-512") which is something even federal governments use to verify and secure data. Many free open-source programs exist for this

4. Keep record of:

• A: The hash value(s) generated
• B: The corresponding hash algorithm(s) used (IE. SHA-512 and RIPEMD-320)
• C: The program name + program-version you chose (click "About" in almost any program's help menu to see the program-version)
• D: For security bonus, re-hash it in other programs and websites to make sure the values always match and no glitches or oddities happen between programs
• E: For security bonus,

5. Keep a record of all relevant hash data. And if the digital Advance Directive gets tampered with, you must prevent the hash data records from also being tampered with and foiling the security plan. So keep hash data and the digital Advance Directive completely isolated (IE. store the securely hashed digital Advance Directive online in a file-sharing account, in a shared-folder that may be downloaded & viewed, but that only you have access to & write-permissions for; store the hash data offline, such as in your wallet on a card that includes your signature, instruction, explanation, and hyperlink to your securely hashed digital Advance Directive)

6. It would help to include a clause like this in your advance healthcare directive:

Copies of this document have equal effect as the originals, including: 1. Signed photocopies. 2. Signed digital copies stored offline (e.g. on smartphones, QR codes, computers), and 3. Signed digital copies stored online privately/publicly. This is to ensure this document is immediately and remotely accessible, and is never lost or ignored. Additionally, to prevent the possibility of digital copies being modified, jeopardized, tampered with, or in any way questionably authentic, I will be hashing the digital copies with secure hashing algorithm(s) and recording the corresponding hash values. They will be recorded on a card/document separate from my digital advance directive copy, and the document/card may include links and locations for the signed digital copies of my advance healthcare directive.

File hash information:

https://en.wikipedia.org/wiki/List_of_hash_functions

https://en.wikipedia.org/wiki/Comparison_of_file_verification_software

https://en.wikipedia.org/wiki/Secure_Hash_Algorithms

Online file hashers:

https://www.fileformat.info/tool/hash.htm

https://defuse.ca/checksums.htm

https://www.virustotal.com

Specific circumstances/states of lifeEdit

These options and ingredients can be explicitly stated, added together in ingredient combos and concept branches, to establish exactly what you want and when you want it, and make this entire process exponentially less stressful to think about. This can get rid of the overanalyzing stage almost entirely, because the nature of these conceptual branches can eliminate "unknown unknowns": unknowable possibilities and unanticipated possibilities while still being completely clear as a contingency plan.

Orders that refuse life-prolonging intervention (in preference of hastening death): Refusal of Artificial/Tubefed Hydration & Nutrition, Do Not Intubate (DNI), Do Not Resuscitate (DNR), Allow Natural Death (AND), Medical Aid In Dying (MAID), Voluntary Stopping of Eating and Drinking (VSED)

Qualifiers: daily, intractable, relentless, severe, intolerable, recurring, long-term, permanent, recrudescent, persistent, irreversible, grievous, terminal

Circumstances: palliative care, hospice care, medical care, nursing home care, psychiatric care, intensive care, home care, private care, public care

Conditions and states (general): pain, mental anguish, agitation, restlessness, dizziness, itchiness, fatigue, weakness, nauseousness

Conditions and states (specific and critical): shortness of breath or difficulty breathing, asphyxiation, cancer, dementia, Alzheimer's, Parkinson's, permanent loss of capacity, persistent delirium, persistent unconsciousness, brain damage, paralyzation, stroke, brain-dead, comatose, vegetative state, locked-in state, terminal illness, disease, infection, body rot, stomach ulceration, stomach incontinence, 1st 2nd or 3rd degree burns/chemical burns, severe injury leading to physical disfigurement, blunt force trauma, laceration, migraines, cluster headaches, the loss of soundness of brain and/or body, functional and/or total blindness and/or deafness, inability to either receive or transmit spoken word and/or written word communication, inability to comprehend basic tasks or basic literature, inability to recognize family/friends/acquaintances, recurring/long-term and/or permanently requiring public care and/or public care.

Final - (Advance Directive Example Forms)Edit

This section starts with Example Prime. Example Prime may be modified to suit your specific plan. Example Prime is a demonstration of almost all the game theory that has been explored so far. It is designed with the priority of suffering/impairment elimination, at the sacrifice of longevity of life. It's broadened to solve legal/ethical challenges, to make everything loud and clear, and to involve the support of others who may also advocate for you.

Example PrimeEdit

I, (FULL NAME) born in (CITY/PROVINCE/COUNTRY) on (DATE OF BIRTH), am the Maker of this Advance Healthcare Directive (also henceforth referred to as "this document"). I have determined this document with sound mind and full understanding of the consequences of my action in doing so. This document is a solemn and legally-binding declaration that dictates my medical and autonomous rights of refusal/consent in all circumstances. This document (and specifically The Contingency Plan) is rooted in both medical jurisprudence and medical rights to refuse any intervention, treatment and encroachment on my person. However, this document and The Contingency Plan is also rooted in autonomous rights, constitutional rights, common-law rights, and human rights to refuse any intervention, treatment, and encroachment on my person (medical, physical or otherwise) regardless of regional restrictions or medical jurisprudence restrictions. This document is a true account of my rational calculated judgement, values, ethical philosophy, and concern for my welfare and security: which all directly oppose the idea that life is innately desirable, and directly oppose the idea that life is ever worth risking or enduring any conceivable pain or harm or debilitation.

This document is also:

1. A Do Not Resuscitate/DNR order in any circumstance that my heart or breathing stops.

2. A refusal of any form of intervention/treatment that would initiate, neglect, or prolong my intolerable pain in any circumstance.

3. A refusal of all life-prolonging treatment if I am subjected to the various circumstances described herein, which will necessarily enact Do Not Resuscitate (DNR), Do Not Intubate (DNI), Voluntary Stopping Eating and Drinking (VSED), and Allow Natural Death (AND) orders for my treatment - this entire process is also previously and henceforth referred to as "The Contingency Plan". And to clarify, "DNI" will equal/denote my refusal of all blood, oxygen, antibacterial agents, dialysis, hydration, nutrition, and any other life-prolonging intervention, injection, intubation and transfusion; the only intervention, injection, intubation and transfusion permitted will be painkillers, sedation, pain-ending and palliative measures. "VSED" will equal/denote my refusal of all nutrition & hydration (including tubefed, artificial, natural, handfed, assisted, spoonfed, oral & all other possible means of nutrition & hydration) even if I appear to cooperate in being fed or hydrated (like in cases of mental incapacity, brain damage, dementia or delirium). VSED may also entail a palliative plan, if my incapacitated-self ever attempts to override the VSED plan. This primarily entails offering substitute palliative support in the case that I ask for food/water. This is an ethical game-theory and failsafe to cure the sensation or pains of thirst/hunger, without actually hydrating or nourishing me. This offers both a safeguard to successful VSED - and safeguard to possible pains/discomforts - so only in the case that palliative measures fail, and my pain/distress winds up intolerable from VSED, will my VSED goal be suspended, until the situation can be taken back under control and followed-through. VSED palliative support may include: humidifiers, non-aqueous glycerin sprays, non-aqueous sprays with methyl cellulose, medical swabs, palliative drugs, palliative injections, palliative suppositories, and if all else fails, total deep-sleep palliative sedation (see Citation 1. and Citation 5. for in-depth guides). And to be fully clear: VSED's exact & absolute objective is to allow my own natural death via VSED, with no exceptions and no interruptions, besides temporary suspension if the pain/distress somehow becomes intolerable.

4. A Release and Assumption of Risk to remove my caregivers' liability of my death, and ensure that in the case that I do end up dying, everything remains in excellent order: nobody risks legal repercussions for my death by following this document. I am ascertaining and calculating all these decisions and plans with my sole discretion and by my sole command. Under the framework and procedures of this document, including under the works/papers cited within, nobody but me is liable for the consequence of my death, I accept and understand all of such responsibility and risk.

Public works and papers cited and studied for palliative, dignified, ethical, and legal VSED:

VSED codified and explained, with state-of-the-art legal, ethical, medical, logical, philosophical, conceptual, and practical guidelines:

Citation 1. Thaddeus Mason Pope: "Voluntarily Stopping Eating and Drinking: A Legal Treatment Option at the End of Life" (One of the most comprehensive legal/medical/philosophical papers ever written on the logistics and practice of VSED, courtesy of law professor Thaddeus Mason Pope, Mitchell Hamline School of Law, Bioethicist, JD, PhD.): https://web.archive.org/web/20190122004842/https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

Citation 2. Thaddeus Mason Pope: "Legal briefing: Voluntarily Stopping Eating and Drinking": https://web.archive.org/web/20190123215025/https://www.researchgate.net/publication/261996427_Legal_briefing_Voluntarily_stopping_eating_and_drinking

Citation 3. Norman L. Cantor: "Avoiding Deep Dementia” (Legal scholar Norman L. Cantor explains why he has an advance directive that calls for voluntary stopping of eating and drinking as a means of ending his life if he develops dementia and reaches particular state(s) of decline - I also plan to similarly implement this strategy and I describe how in The Contingency Plan.): https://web.archive.org/web/20190318220509/https://onlinelibrary.wiley.com/doi/full/10.1002/hast.865

Citation 4. Norman L. Cantor: "My Revised Advance Directive": https://web.archive.org/web/20190127122933/http://blog.petrieflom.law.harvard.edu/2017/04/20/changing-the-paradigm-of-advance-directives/

Citation 5. Phyllis Shacter: "The VSED Choice: Voluntary Stopping Eating & Drinking" (Phyllis describes attending her Husband's successful VSED to end a non-terminal but permanent/degenerative condition (Alzheimer's) with medical, legal, and care-giving supplies cited): https://web.archive.org/web/20160414094516/http://www.phyllisshacter.com/the-vsed-choice/

The Contingency Plan:

No form of disagreement will diminish the strength or orders of this document. I don't view life as inherently good or desirable, and I have concluded and realized life contains risks & possibilities of grievous, unacceptable and intolerable pains, impairments, conditions, and states that I refuse to ever endure: which is when the DNR, DNI, VSED, palliative support only & Allow Natural Death orders will become effective. Here is another description of The Contingency Plan denoting when those orders become effective:

If life permits severe/relentless/intolerable suffering, the loss of soundness of my brain or body, the loss of a dimension of cognition (such as the loss of sight, communication, navigation, permanent/indefinite loss of mental capacity, lucidity, or consciousness), and/or any long-term, perpetually recurring, or permanent admittance to public and/or private care: then I refuse all treatment that would prolong my life. Once my refusal of all life-prolonging treatment is in effect, my care must only entail palliative care, sedation, painkillers, DNR, DNI, VSED, and Allowing Natural Death – if my caregiver(s) ever object to these instructions, I demand to be released from all care, and/or transferred to people who will comply. The overall objective and absolute priority of my healthcare must always be: "That which maximally reduces my pain & suffering, and maximally expedites the end of my pain, suffering, persistent unconsciousness & all persistent cognitive/physical impairment - even if my life is at risk & death is hastened as a result." And if I am ever overtaken by dementia, or any brain damage, injury, or impairment which changes my persona into one that exhibits careless, emotionless, indifferent, placid, uncomprehending, uncommunicative, reckless, or agitated states, or seeks to undermine or override this advance directive: that persona is not to be given undermining or overriding power. If I do not return from that persona, to my mental capacity, lucidity, & independence from all public care & private care within 30 days, withdraw all life-support from that persona via the DNR, DNI, VSED, palliative support only & Allow Natural Death process outlined within this document, and simply protect my suffering & the full completion of the process, through total deep-sleep palliative sedation if necessary.

The following list denotes another framework of The Contingency Plan to include even more circumstances/states, any of whose daily, recurring, or permanent presence will enact my refusal of all life-prolonging treatment & enact the DNR, DNI, VSED, palliative support only & Allow Natural Death orders:

- severe and/or intractable pain, mental anguish, agitation, or dysphoria(s)

- severe and/or intractable stomach ulceration, migraines, cluster headaches

- severe and intractable shortness of breath or difficulty with breathing

- severe and intractable dizziness/itchiness/fatigue/weakness and/or nauseousness

- intractably being the source of foul and putrid smells and/or total unremitting incontinence

- blindness (total or functional)

- braindead, comatose, vegetative, paralyzed, persistently unconscious, or locked-in state

- terminal and/or grievously intractable illness, disease, cancer, infection, body rot, etc.

- severe injury resulting in ongoing pain and/or bodily disfigurement and/or incapacitation (e.g. severe 2nd or 3rd degree burns, asphyxiation, chemical burns, falls, car wrecks, blunt force trauma, laceration, etc.)

- inability to communicate (to both receive and transmit spoken word and written word)

- irreversible loss of capacity, or permanent and/or indefinite loss of independence or lucidity (by any means, including and not limited to Alzheimer’s, brain damage, dementia, mysterious delirium)

- any state(s) I don't 100% recover from within 30 days wherein I am subjected to artificial, hand-fed, or any form of assisted hydration/nutrition, and/or medical intervention, and/or private/public care

- any recrudescent or permanent conditions, which result in recurring, permanent, or long-term medical care, nursing home care, psychiatric care, intensive care, home care, and any other form of private care and/or public care

Postscript:

Copies of this document have equal effect as the originals, including: 1. Signed photocopies. 2. Signed digital copies, stored offline (e.g. on smartphones, QR codes, computers), and 3. Signed digital copies, stored online privately/publicly. This is to ensure this document is immediately and remotely accessible, and is never lost or ignored. Additionally, to prevent the possibility of digital copies being modified, jeopardized, tampered with or in any way questionably authentic, I will checksum any digital copies of this document with a secure hashing algorithm. I will record the relevant corresponding hash data. The hash data will be recorded separately from the digital copy of this document, in a video, photo, and/or on a signed document/card that may be kept on my person, that verifies and points to the location(s) of the digital copy of this document.

I understand that as long as I have capacity, I may revoke or reinstate this document at any time. But unless revoked by me, this document is always instated. And revocation only equals suspension of the exact parts/clauses I revoke. And if I ever lose capacity again (whether after partial revocation, during mid-revocation process, or otherwise) this document always resumes full efficacy: unless I specify otherwise, or permanently terminate this document.

If any part(s) of this document are found to be invalid or illegal, that will not in any way affect the remaining parts, or the overall objective and absolute priority of this document.

If anything or anyone ever invalidates, disallows, fails to initiate and finish, or in any way infringes on The Contingency Plan, or objects to The Contingency Plan, then I invoke the authority and duty of my medical proxy, ethics committee, Public Guardian and Trustee, or equivalent, to protect my human rights and stop the infringement of The Contingency Plan, and to transport me to a region on Earth that is ready, able, and willing to initiate and finish The Contingency Plan (at the expense of my estate if necessary).

I explicitly forbid all attempts to undermine or override this advance healthcare directive for any reason, including on the basis that I would have chosen otherwise, such as if certain information or technology were available, or raising attention/questions/doubts about phenomena such as "ableism", "dyspraxia", "agnosia", "eating disorders", and the "then-self/now-self" problem.

Maker signature

Signed and initiated by me, the Maker, [FULL NAME] in (CITY/PROVINCE/COUNTRY) and on the date of __________________________.

_______________________________          _______________________________

Signature of Maker                                              Printed name of Maker

__________________________________________________________________________

Address of the Maker

Witness signature(s)

This document was signed by me, the Maker, in the presence of my witnesses, to whom I have proven my identity, and hereby verify this advance directive was made with my fully informed, deliberated, calculated, self-determined, and complete mental capacity:

_________________________________________________________________________________________ 

(Signature of 1st witness + Date (YYYY-MM-DD)

_________________________________________________________________________________________ 

Printed name of 1st witness

__________________________________________________________________________

(Signature of 2nd witness + Date (YYYY-MM-DD)

__________________________________________________________________________

Printed name of 2nd witness)

My Medical Proxy's Authorities & Duties:

My proxies' authority/duty is to initiate and finish The Contingency Plan and ensure it is in excellent order, even if withholding or stopping of treatment will bring about my death.

My proxies also have the authority to request Medical Aid in Dying and/or request euthanasia for me to expedite The Contingency Plan, if such requests are legal and medically appropriate in my jurisdiction of residence.

My proxies have the same rights I would have with respect to my medical records (e.g. may see them, may obtain copies of them, may consent to disclosure of them).

My proxies also have the authority/duty to engage in the following activities with respect to healthcare and personal-care professionals and institutions:

· requisitioning information

· signing waivers and release forms for The Contingency Plan

· hiring and firing (of professionals) to initiate and protect and finish The Contingency Plan

· admitting and discharging (to/from institutions) to initiate and protect and finish The Contingency Plan

- the authority & duty to transport me to a region on Earth that is ready, able, and willing to initiate and finish The Contingency Plan (at the expense of my estate if necessary)

· pursuing any legal action in my name regarding my healthcare and human rights, and at the expense of my estate if necessary, force compliance with my advance healthcare directive, and seek actual or punitive damages if I am ever kept alive against my consent

My Medical Proxies

My medical proxies (also known as proxies, or Powers of Attorney for Healthcare). The initial proxy, and all substitute proxies, have consented to act in my place and understand what doing so entails. Their signatures are below:

_________________________________________________________________________________________ 1st - (Initial proxy) Signature / Address / Phone / Date (YYYY-MM-DD)

_________________________________________________________________________________________ 

2nd - (Substitute proxy) Signature / Address / Phone / Date (YYYY-MM-DD)

_________________________________________________________________________________________ 

3rd - (Substitute proxy) Signature / Address / Phone / Date (YYYY-MM-DD)

_________________________________________________________________________________________ 

4th - (Substitute proxy) Signature / Address / Phone / Date (YYYY-MM-DD)

NOTARIZATION

On this ____day of _______________, 20___ in the City/Town of_________________ in the state/province of _________________, personally appeared before me the aforesaid declarant and principal (the Maker), to me known to be the person described in and who executed the foregoing instrument and acknowledged that he/she executed the same as his/her free act and deed. 

___________________________________ Notary Stamp:

Signature/position of Notary Public

____________________________________

My commission expires (date)

Record of people, institutions, electronic devices, and online storages that hold a copy of this advance directive:

1.________________________________________________________________________________

2.________________________________________________________________________________

3.________________________________________________________________________________

4.________________________________________________________________________________

5.________________________________________________________________________________

Person / Relationship / Address / Device / Website Date (YYYY-MM-DD)

• Insert this footer on every page of your Advance Directive and have it initialed during the official final signing process:

Maker initials: ______ Witness #1 initials: _____ Witness #2 initials: _____

Other ExamplesEdit

1. Compassion Choices (massive list of resources - including a menu to select Advance Directive forms from all 50 States of America) https://compassionandchoices.org/end-of-life-planning/plan/advance-directives/ Archived version: https://web.archive.org/web/20190319235059/https://compassionandchoices.org/end-of-life-planning/plan/advance-directives/

2. Legal Depot Canada example forms of "personal directives / living wills / medical powers of attorney" (select your province, make sure this is legally binding)

A: Personal directives / living wills https://www.lawdepot.ca/contracts/living-will-personal-directive/?ldcn=healthdir&loc=CA

B: Medical power of attorney https://www.lawdepot.ca/contracts/living-will-personal-directive/?loc=CA&ldcn=poamed

3. Legal Depot United States example forms of "living will / medical power of attorney" (select your state, make sure this is legally binding) A: https://www.lawdepot.com/contracts/living-will-medical-power-of-attorney/?loc=US&ldcn=poamed

4. End of Life Washington (has Advance Directive template for VSED and for VSED specialized for dementia/Alzheimer's) https://endoflifewa.org/wp-content/uploads/2014/07/Alzheimers.Disease.and_.Dementia.Mental.Health.Advance.Directive.10.2015.pdf Archived version: https://web.archive.org/web/20151122232153/http://endoflifewa.org/wp-content/uploads/2014/07/Alzheimers.Disease.and_.Dementia.Mental.Health.Advance.Directive.10.2015.pdf

End of Life Washington's form with excellent Notary guideline: https://endoflifewa.org/wp-content/uploads/2014/03/EOLWA-Advance-Directive-12-18-Large-Print.pdf Archived version: https://web.archive.org/web/20190220051731/https://endoflifewa.org/wp-content/uploads/2014/03/EOLWA-Advance-Directive-12-18-Large-Print.pdf

5. End of Life Choices New York (has Advance Directive template for VSED and for VSED specialized for dementia/Alzheimer's) https://endoflifechoicesny.org/wp-content/uploads/2018/03/3_24_18-Dementia-adv-dir-w-logo-no-donation-language.pdf Archived version: https://web.archive.org/web/20180831175444/http://endoflifechoicesny.org/wp-content/uploads/2018/03/3_24_18-Dementia-adv-dir-w-logo-no-donation-language.pdf

6. Professor of Law Thaddeus Mason Pope's Advance Directive:

https://web.archive.org/web/20180105075347/http://thaddeuspope.com/consent/advancedirectives.html

7. Right to Die Canada "Living Will" example:

https://web.archive.org/web/20160519131541/http://righttodie.ca/documents/Living%20Will.pdf

8. Philippines Advance Directives:

https://www.philstar.com/lifestyle/health-and-family/2010/11/02/625884/why-you-need-living-will (Archived version: https://archive.fo/sJxvG )

http://www.myfinancemd.com/creating-living-will-cpr-dnr-not-resuscitate/ (Archived version: https://web.archive.org/web/20180723061747/http://www.myfinancemd.com/creating-living-will-cpr-dnr-not-resuscitate/ )

Miscellaneous Edit

German VSED information: https://www.sterbefasten.com

France - ending life support for permanently "unaware" patients http://blog.petrieflom.law.harvard.edu/2015/06/22/human-rights-tribunal-upholds-frances-policies-on-ending-life-support-for-permanently-unaware-patients/ Archived version: https://web.archive.org/web/20190220090222/http://blog.petrieflom.law.harvard.edu/2015/06/22/human-rights-tribunal-upholds-frances-policies-on-ending-life-support-for-permanently-unaware-patients/

Right To Die Treatise (1400 pages)

Authored by three legal scholars with 20+ years of experience each:

https://books.google.ca/books?id=qSRYYfZAYnwC&pg=SA1-PA10&lpg=SA1-PA10&source=bl&ots=0dhh3D8Zyr&sig=ACfU3U2ssNje5lTOvWneGsqRsXLnfh6MnQ&hl=en&sa=X&redir_esc=y#v=onepage&q&f=false

https://www.amazon.com/Right-Die-End-Life-Decisionmaking/dp/0735546657

Additional Repository of free ethical/legal/philosophical papers written by each author:

(Downloading/viewing a paper sometimes re-directs to a sign-up page, you can scroll down and solve the CAPTCHA instead) Author #1: Thaddeus Mason Pope https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=180178 Author #2: Kathy L. Cerminara https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=145233 Author #3: Alan Meisel https://papers.ssrn.com/sol3/cf_dev/AbsByAuth.cfm?per_id=81428

VSED further explored:

Partly because VSED is underexplored by major medical associations, it is referred to by at least eight different terms.154  Some refer to it as “Voluntary Refusal of Food and Fluid” (VRFF).155  Others refer to it as “Voluntary Terminal Dehydration” (VTD),156 “Voluntary Death by Dehydration” (VDD),157 or just “Terminal Dehydration.” 158  Still others refer to it as “Stopping Eating and Drinking” (STED),159 “Patient Refusal of Hydration and Nutrition” (PRHN),160 or as “Indirect Self-Destructive Behavior” (ISDB).161 The fundamental concept described by these various names is basically the same.  We use “VSED” because it seems to have more currency in recent academic and professional literature.162 https://open.mitchellhamline.edu/cgi/viewcontent.cgi?article=1279&context=facsch

Nurses' Experiences with Hospice Patients Who Refuse Food and Fluids to Hasten Death https://www.nejm.org/doi/full/10.1056/NEJMsa035086 Archived version: https://archive.fo/0xXX6

Voluntary refusal of food and fluids has been proposed as an alternative to physician-assisted suicide for terminally ill patients who wish to hasten death. There are few reports of patients who have made this choice.

METHODS We mailed a questionnaire to all nurses employed by hospice programs in Oregon and analyzed the results.

RESULTS Of 429 eligible nurses, 307 (72 percent) returned the questionnaire, and 102 of the respondents (33 percent) reported that in the previous four years they had cared for a patient who deliberately hastened death by voluntary refusal of food and fluids. Nurses reported that patients chose to stop eating and drinking because they were ready to die, saw continued existence as pointless, and considered their quality of life poor. The survey showed that 85 percent of patients died within 15 days after stopping food and fluids. On a scale from 0 (a very bad death) to 9 (a very good death), the median score for the quality of these deaths, as rated by the nurses, was 8.

Patients with neurologic diseases such as amyotrophic lateral sclerosis may wish to hasten death but be unable to administer the lethal medication themselves, as required by the Oregon law. 28 percent of hospice nurses in Oregon did not respond to our survey, and their experiences are therefore not represented.

Linda Ganzini, M.D., M.P.H. Elizabeth R. Goy, Ph.D. Lois L. Miller, Ph.D., R.N. Theresa A. Harvath, R.N., Ph.D., Ann Jackson, M.B.A. Molly A. Delorit, B.A.

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