Advance Care Plan

ADVANCE CARE PLAN

Date: ______

I,______(name)

Of ______

______(Address)

am of sound mind. I have read and understand the importance of this document. I have also had this document explained to me and had all my questions answered to my satisfaction. I request that my stated choices recorded below, are respected by my family, my Enduring Guardian/s (if appointed), and by my doctors. I also understand that the doctors will only provide treatment that is medically appropriate.

□I have a legally appointed Enduring Guardian for substitute medical decision-making. (Please initial this box and attach a copy of the completed Enduring Guarding appointment to this plan if you have appointed Enduring Guardian)

My nominated substitute decision maker/s on my behalf (please include their contact details and relationship to you.)

Name:______Relationship:______

Address:______

______Phone: ______

Name:______Relationship:______

Address:______

______Phone: ______

CPR (Cardiopulmonary Resuscitation)Initial the box that you want.

□I do want CPR if it is medically appropriate.

or

□I only want CPR if the doctors expect a reasonable outcome.

or

□I do not want CPR at all.

To me a reasonable outcome means:

______

______

______

Plans for life-prolonging treatments (life prolonging treatment means any medical procedure, device or medication to keep you alive (eg ventilator, dialysis, artificial nutrition. Such treatment does not mean that your disease will be cured or that you will get back to the way you were before having the treatment).

Preferences regarding life-prolonging treatment goals

(Please mark the small boxes next to your choices and cross out the big statement boxes that you DO NOT want).









Specific requests with regard to medical care

(If you DO NOT have specific requests, please put a large cross through whole section)

There are some medical treatments that I would not choose to accept. I have listed these treatments as follows:

______

______

______

______

______

______

______

______

Current health status (Please initial the box next to your choice).

□I do not have any chronic (long-term) medical conditions(health problems) at the time of writing this plan (go to next section).

□I do have one or more chronic (long-term) medical conditions (health Problems) at the time of writing this plan.

My understanding of my long term health problems are:

______

______

______

Personal statement

(Please initial box if you wish to make this statement. If you DO NOT want to complete this statement, please put a big cross through the whole section)

□I do not want to live in a way that is intolerable (unbearable) to me.

□I would find my life intolerable (unbearable) if:

______

Values and Beliefs (it may be helpful to record these so others understand them)

Who or what supports you when you are faced with serious challenges?

______

______

Do you have any religious or spiritual views you would like to record?

______

______

What are the things about your life that really matter to you?

______

______

Do you believe in miracles?□Yes/□No

Goals (what is important to you? What do you personally define as ‘living well’?

How important is being able to get around by yourself, the ability to recognise your family, to prolong life for as long as possible? How important is it for you to be at home?

______

______

______

Other points that are important to me (you may want to write specific care requests, spiritual care wishes, or people you would like to have with you).

If I am nearing my death, I want the following (list things that would be important to you): If you have other end-of-life wishes, eg organ or body donation, you may wish to attach your documentation to this plan. NB. It is important in this case to register as a donor and discuss your wishes with your next-of-kin/family.

______

______

Preferred place to be cared for:

□ Hospital□Home□Care Home

If there is not enough room to write all your requests and wishes, please attach further pages as necessary. It is recommended that all additional pages are signed, dated and witnessed.

I ______hereby declare that the information completed above is a true record of my wishes on this date.

Signature ______Date ______

(your signature)

Witness signature ______Date ______

(Preferably your ‘person responsible’)

Witness name ______Relationship ______