SCHEDULE 1 – REFUSAL OF TREATMENT CERTIFICATE: COMPETENT PERSON – MENTAL HEALTH ACT 1988

Refusal of Treatment Certificate: Competent Person

We certify that we are satisfied—

(a)  that ........................................................... (name of patient) has clearly expressed or indicated a decision, in relation to a current condition, to refuse—

*medical treatment generally;

or

*medical treatment, being ................................................................
(specify particular kind of medical treatment);

(b)  that the patient's decision is made voluntarily and without inducement or compulsion;

(c)  that the patient has been informed about the nature of his/her current condition to an extent which is reasonably sufficient to enable him/her to make a decision about whether or not to refuse medical treatment generally or of a particular kind (as the case requires) and that he/she has appeared to understand that information; and

(d)  that the patient is of sound mind and has attained the age of 18 years.

Dated:

Signed..........................................................(Registered Medical Practitioner)

Signed ...................................................................................(Another Person)

Patient's current condition

The patient's current condition is .................................... (describe condition)

Dated:

Signed: ......................................................................................................... (To be signed by the same registered medical practitioner)

Verification to be completed by patient, if physically able to do so.

In relation to my current condition, I refuse—

*medical treatment generally

or

*medical treatment, being.................................................................
(specify particular kind of medical treatment).

I give the following instructions as to palliative care:

 

Dated:

Signed ................................................. (Patient)

NOTICE OF CANCELLATION (for completion where patient cancels the certificate under section 7 of the Medical Treatment Act 1988)

I cancel this certificate

Dated:

Signed:................................................. (Patient)

or

The patient clearly expressed or indicated a decision to cancel this certificate on                  (Date).

Signed ............................................... (Person witnessing patient's decision)

*Delete whichever is not applicable

NOTE: "Medical treatment" means the carrying out of—

(a)  an operation; or

(b)  the administration of a drug or other like substance; or

(c)  any other medical procedure—

but does not include palliative care.

"Palliative care" includes—

(a)  the provision of reasonable medical procedures for the relief of pain, suffering and discomfort; or

(b)  the reasonable provision of food and water.

The refusal of palliative care is not covered by the Medical Treatment Act 1988.