Northern Territory Consolidated Acts

RIGHTS OF THE TERMINALLY ILL ACT 1995 - SCHEDULE

Schedule

section 7

REQUEST FOR ASSISTANCE TO END MY LIFE IN A HUMANE AND DIGNIFIED MANNER

I, have been advised by my medical practitioner that I am suffering from an illness which will ultimately result in my death and this has been confirmed by a second medical practitioner.

I have been fully informed of the nature of my illness and its likely course and the medical treatment, including palliative care, counselling and psychiatric support and extraordinary measures that may keep me alive, that is available to me and I am satisfied that there is no medical treatment reasonably available that is acceptable to me in my circumstances.

I request my medical practitioner to assist me to terminate my life in a humane and dignified manner.

I understand that I have the right to rescind this request at any time.

Signed:

Dated:

DECLARATION OF WITNESSES

I declare that:

        (a)     the person signing this request is personally known to me;

        (b)     he/she is a patient under my care;

        (c)     he/she signed the request in my presence and in the presence of the second witness to this request;

        (d)     I am satisfied that he/she is of sound mind and that his/her decision to end his/her life has been made freely, voluntarily and after due consideration.

Signed:                 Patient's Medical Practitioner

I declare that:

        (a)     the person signing this request is known to me;

        (b)     I have discussed his/her case with him/her and his/her medical practitioner;

        (c)     he/she signed the request in my presence and in the presence of his/her medical practitioner;

        (d)     I am satisfied that he/she is of sound mind and that his/her decision to end his/her life has been made freely, voluntarily and after due consideration;

        (e)     I am satisfied that the conditions of section 7 of the Act have been or will be complied with.

Signed:                     Second Medical Practitioner

[Where under section 7(4) an interpreter is required to be present]

DECLARATION OF INTERPRETER

I declare that:

        (a)     the person signing this request or on whose behalf it is signed is known to me;

        (b)     I am an interpreter qualified to interpret in the first language of the patient as required by section 7(4);

        (c)     I have interpreted for the patient in connection with the completion and signing of this certificate;

        (d)     in my opinion, the patient understands the meaning and nature of this certificate.

Signed:                     Qualified Interpreter.