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Support and promote life quality

lifecircle | Living will & additional personal statement

My Living will
Title
First name
Name
Date of Birth

I hereby declare that I am in full possession of my ability to judge and I have decided the
following after careful consideration:
Should I, by illness or by accident, lose my ability to judge and should I not have, from a medical
point of view, any chance at all to regain the ability to judge, the points listed below must be
respected according to my right to full self-determination:
Please mark the points according to your wishes.
1. Concerning life-prolonging measures I wish the following:
yes

no

Resuscitation
Transfer to an intensive care station
Artificial respiration
Artificial nutrition
Use of Antibiotics
Use of chemotherapy

2. Palliative therapy to relieve pain, breathing problems, and other complaints:
I wish to receive any type of analgesics and sedatives in the dose that
guarantees the best quality of life for me.
I take explicitl