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7/28/2019 Advance Care Plan Blank

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ADVANCE CARE PLAN

Date: ____________ I, ___________________________________ (name)Of ____________________________________

____________________________________ (Address)am of sound mind. I have read and understand the importance of this document. I have alsohad 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 EnduringGuardian/s (if appointed), and by my doctors. I also understand that the doctors will onlyprovide 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 appointmentto this plan if you have appointed Enduring Guardian)

My nominated substitute decision maker/s on my behalf (please include their contactdetails 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 medicalprocedure, 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 tothe 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 boxesthat you DO NOT want).

This Advance Care Plan will be used to guide future medical decisions ONLY when you lose the ability to make orcommunicate your medical treatment decisions yourself. The law requires that this statement of your wishes must betaken into account when determining your treatment



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 listedthese 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 completethis 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:

__________________________________________________________________

I request all efforts made to sustain my life (keep me alive). I would accept all

offered medical treatment in a life-threatening situation. I understand that Imay need long team, ongoing supportive care and medical treatment for therest of m life.

I request life prolonging treatment that will support (help) me to recover andlive in a way that is meaningful to me, as described in this plan.

In the situation where it is reasonably certain that I will not recover to live in away that is meaningful to me, then I request only medical treatment that willpromote my comfort and dignity. I understand that these treatments will be

offered as palliative care management and will not prolong my life.

I request that my doctors, in consultation with my family and friends, makethe medical treatment decisions that they feel are in my best interests. I wantthem to know that their decisions will be the right decisions for me.



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

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 ‘livingwell’?How important is being able to get around by yourself, the ability to recognise yourfamily, 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 carerequests, 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 toyou): If you have other end-of-life wishes, eg organ or body donation, you may wish toattach your documentation to this plan. NB. It is important in this case to register as adonor and discuss your wishes with your next-of-kin/family.______________________________________________________________________________________________________________________________________Preferred place to be cared for:

□ Hospital □Home □Care HomeIf there is not enough room to write all your requests and wishes, please attach furtherpages as necessary. It is recommended that all additional pages are signed, dated andwitnessed.

I ________________________________ hereby declare that the information completed aboveis a true record of my wishes on this date.

Signature ______________________________ Date ___________________ (your signature)

Witness signature ________________________ Date ___________________ (Preferably your ‘person responsible’)

Witness name ___________________________Relationship _____________

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