The Living Will Declaration Form serves as a crucial legal and medical document in the Netherlands, enabling individuals to maintain autonomy over their healthcare decisions even when they become incapacitated. This document becomes particularly important in situations involving serious illness, end-of-life care, or unexpected medical emergencies. It is governed by Dutch healthcare legislation, including the Medical Treatment Contracts Act (WGBO) and the Termination of Life on Request and Assisted Suicide Act, which provide the legal framework for advance directives. The form typically includes the appointment of healthcare representatives, specific medical treatment preferences, end-of-life care decisions, and may also address euthanasia wishes as permitted under Dutch law. Healthcare providers are legally obligated to consider these advance directives in their decision-making process, making this document an essential tool for ensuring patient autonomy and dignity in healthcare.
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1. Personal Information and Declaration: Full legal name, date of birth, address, and BSN (Dutch social security number). Includes a statement declaring sound mind and voluntary execution of the document.
2. Appointment of Healthcare Representative: Designation of primary and alternate healthcare representatives (zorgvertegenwoordiger) who can make medical decisions when the declarant becomes incapacitated.
3. General Medical Treatment Preferences: Overall healthcare philosophy and general preferences regarding life-sustaining treatments, pain management, and quality of life considerations.
4. Specific Medical Directives: Detailed instructions regarding specific medical treatments such as resuscitation (DNR), artificial nutrition/hydration, mechanical ventilation, and organ donation.
5. End-of-Life Care Preferences: Specific wishes regarding palliative care, hospice care, and preferred place of death if possible.
6. Euthanasia Statement: Clear statement regarding wishes for euthanasia under specific circumstances, as permitted under Dutch law.
7. Execution and Witnessing: Signature section with date, including witness signatures and their personal information as required by Dutch law.
1. Religious or Cultural Preferences: Specific instructions based on religious beliefs or cultural practices that should be respected during medical treatment and after death.
2. Specific Medical Conditions: Additional directives related to existing medical conditions or specific anticipated health scenarios.
3. Pregnancy Provisions: Specific instructions that apply if the declarant is pregnant at the time medical decisions need to be made.
4. Mental Health Treatment Preferences: Specific instructions regarding psychiatric or psychological treatment preferences if needed.
5. Digital Legacy Instructions: Preferences regarding handling of digital accounts and assets after death.
1. Schedule A - Physician Confirmation: Form for the attending physician to confirm discussion of the living will with the declarant and assessment of mental capacity.
2. Schedule B - Witness Statements: Detailed statements from witnesses confirming the voluntary nature of the declaration and the declarant's mental capacity.
3. Schedule C - Healthcare Representative Acceptance: Written acceptance by appointed healthcare representatives acknowledging their responsibilities and commitment.
4. Schedule D - Medical History Summary: Optional summary of relevant medical history and conditions that may impact treatment decisions.
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