My "Advance Helathcare Directive"

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ADVANCE HEALTHCARE DIRECTIVE
(A) Advance health directive including Power of Attorney for Health Care Decisions and wishes of Tito Mathson (Male, Date of Birth - 9th July 1949)residing at ......

(B) To my family, My Physician (any qualified Medical Doctor attending to me at any given time), My Clergyman ( The Priest of Mar Thoma Church Prim Rose Road, Bangalore 560001 and /or Immanuel Mar Thoma Church, Eraviperoor, Tiruvalla Taluk, Keralam, India; and my Lawyer Mr. S. Nagraj, Bangalore, India.

(C) This Directive is written and signed by me on 20thth of November 2010 in the presence of two witnesses, who are not in any way beneficiaries of any of my assets ( both movable and immovable), and I am doing so in full command of my faculties and consciousness. Original of this document, has been given to my wife Mariam Mathson. The following people have been given one copy each of the same: (1) Mathson ( my brother), (2) Mrs. Abraham ( my sister), (3) Ms. Mathson ( my elder daughter), (4) Ms Mathson ( my younger daughter) as well as the TWO witnesses who have signed this document below.

(D) Statement of Desires :

If I become incapable of giving informed consent regarding my healthcare decision and if I develop any incurable or progressive, degenerative or terminal disease and no cure is available, and treatment if any, may only prolong the dying process, I request that my Physicians and other healthcare providers follow this directions below.

Accordingly I wish that following be adhered to:-

(1) Caring and supportive nursing and medical care to relieve pain and suffering including narcotics to relieve pain and suffering even if respiration is depressed and even if my death is hastened by such medication.
(2) Food and fluids to be offered, but not forced upon me as long as I am conscious to take them by mouth, by my own command.
(3) Pacemaker or any device that substitutes for normal heart-beat :– Not to be applied on me.
(4) Respirator / Ventilator :– Not to be applied on me.
(5) Cardio-pulmonary Respirator ( CPR) or Intervention given by Man, Machine or Drugs :– Not to be applied on me.
(6) Feeding by Tube ( Tube placed in to the stomach or bowel) to give fluid / nutrition :– Not be applied on me.
(7) Intravenous Tube for feeding or hydration :– Not be be given to me.
(8) Antibiotics to treat Pneumonia or other infections :– Not to be given to me.
(9) Cancer Therapy ( Radiation / Chemotherapy ) – Not to be given tome.
(10) Blood Transfusion :– Not to be given to me.
(11) Diagnostic procedures or Tests or further tests to monitor my failing condition :– Not to be done / applied to me.
(12) Surgery :- Not to be done on me.





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(13) Paracetamol, Aspirin may be used for pain relief or whatever purpose, but if it prolongs my dying process :– Not to be given to me.

(!4) Donation of my body parts – Allowed by me ( any part).

(15) Autopsy :– Not to be done on me. except as may be required by law.

(16) Disposal of Body :– Any mode that is most convenient to my family members, friends or any one else in charge of the same. Cremation, burial, or donation of entire body or parts to any Medical College/ Hospital for studies are acceptable to me.

(E) FURTHER, THE FOLLOWING DETAILS OF MY WISH SHOULD BE RESPECTED AND FOLLOWED:-

(a) Under no circumstances should I be taken to Hospital without my own consent.
(b) I ask that drugs be mercifully administered to me for terminal suffering even if they hasten the moment of death including narcotics or any other drugs to alleviate pain irrespective of the drugs’ side effects, if any, what so ever.
(c) It may be noted that I do not fear death as I fear indignity of physical deterioration, dependence and hopeless pain.

This request is made after very careful consideration on my part, as well as discussion with my spouse and two daughters and close friends.

I recognize that it places a heavy burden upon my family members, Caretakers which includes Doctors, Nurses and Friends and Relatives and well wishers. It is with the intention of sharing the said Burden & responsibility, and mitigating any feeling of guilt or fear of legal culpability that my caretakers and any or all of the above people may have, that this statement is made.

This statement consists of TWO pages and is signed by me and the two witnesses on each of two pages. All signatories have signed here in the presence of all of them on the same date and at the same place. Witnesses are persons who have nothing to gain in any manner by my death.




Tito Mathson
Name & Signature Date Place – Bangalore Spouse- Mrs Mathson…………







Witness-1 ( Name, Address & Tel No.) ( Witness-2: Name Address & Tel No.)