Northern Territory Consolidated Regulations Northern Territory Consolidated RegulationsNOTICE OF DIRECTION PURSUANT TO NATURAL DEATH ACT
To: The Medical Practitioner responsible for my treatment at
such time when I am suffering from a terminal illness*
I,
...............................................................................,
declare that I am of
(name of person making direction)
sound mind and have attained the age of 18 years AND in the event that I may suffer from a terminal illness* within the meaning of the Natural Death Act AND having the desire not to be subjected to extraordinary measures, namely medical or surgical measures that prolong life, or which are intended to prolong life, by supplanting or maintaining the operation of bodily functions that are temporarily or permanently incapable of independent operation, or to particular extraordinary measures specified below, DO HEREBY make the direction that I not be subjected to:
± extraordinary measures generally
± extraordinary measures, being
..............................................
(specify particular kind of measures)
Dated ......................... 19.............
Signature of person making direction: ..........................................
WITNESSED in the presence of 2 witnesses who have attained the age of 18 years
1 .......................................... 2 ..........................................
.......................................... ..........................................
.......................................... ..........................................
(Name, address, occupation) (Name, address, occupation)
* Terminal illness means any illness, injury or degeneration of mental or physical faculties:
(a) such that death would, if extraordinary measures were not undertaken, be imminent; and
(b) from which there is no reasonable prospect of a temporary or permanent recovery, even if extraordinary measures were undertaken.
± Delete whichever is not applicable.