Author: Blythe Scully

Advance Care Plan / Directive

Please consider all questions on this template. Cross out sections/s you do not wish to answer at this time. Remember to make copies of this plan and give to your GP, your family and trusted friends.

Name: 							DOB: 
Address: 
Completed by Proxy - Name:				Relationship:

If I cannot speak for myself, I would like my doctor to talk about my health care and medical problems with the following person/s:

Name | Contact Numbers

I have legally appointed the following:
| Yes/No | | Copies of legal documents held by (name and contact)

Enduring Guardian 
(for health decisions)

Enduring Power of Attorney | | |

If I am very sick or badly injured and others need to make medical decisions for me, please consider my following statements when making substitute decisions:
The following things are important to me, and I want them to be considered in any decisions that are made on my behalf: (should you wish to attach an additional page for this question-please remember to sign, date and witness:

Cardio Pulmonary Resuscitation (CPR) Initial the box that matches your choice)
If my heart or breathing stops due to old age or irreversible (not curable) health problems my choice, if CPR is a treatment option, would be:

☐    Please try to restart my heart or breathing (Attempt CPR)

☐ Please allow me to die a natural death. Do not try to restart my heart or breathing (No CPR)
 
☐    I cannot answer this question.  Let my doctor decide.

Name:					 Signature:				 Date: Tuesday, 6th September 2016
or Proxy

Witness name:				 Signature:				 Date: Tuesday, 6th September 2016

Review date/s:			 			 			 			

Personal Values
Please consider my personal values for the following statements if I am unable to make my own decisions in the future. (Put your initials in the box that is your response to each statement)

I would find life to be acceptable OR difficult but bearable OR unbearable if, for the rest of my life:

| Acceptable | Difficult but bearable | Unbearable
I do not recognise my family and loved ones | | |
I do not have control over my bladder an bowels | | |
I cannot feed myself, and cannot wash myself, and cannot do my own personal grooming and dressing | | |
I cannot move myself around in or out of bed and rely on other people to reposition (shift or move) me | | |
I can no longer eat or drink and need to have food given to me through a tube in my stomach | | |
I cannot talk, read and write | | |
I can never have a conversation with others because I do not understand what people are saying | | |
I do not get enjoyment from many of the things that I have always enjoyed | | |
 
Thinking about end of life:
   Please initial the statement which is closest to your personal belief
I am frightened of dying and do not want to think about it happening to me or my loved ones. I do not discuss death or dying with others |
Dying is a fact of life. You just have to deal with it when it happens. I hope that I can talk about it with loved ones and others before my time comes. |
Dying is a natural part of life. I am comfortable discussing death and dying with my loved ones and others. I want to be prepared for when my time comes. |

When my time for natural dying comes, if possible, I would like to be cared for
☐ At home or in a home like environment
☐ In a hospital or hospital like environment
☐ I do not know. I am happy for my family / person responsible to decide

Name:					 Signature:				 Date: Tuesday, 6th September 2016
or Proxy

Witness name:				 Signature:				 Date: Tuesday, 6th September 2016

Review date/s:			 			 			 			

Specific requests with regard to medical care (Please initial the box if you wish to identify specific treatment limitations. If you DO NOT have specific requests, please cross out this section)

☐  	I DO NOT WANT to have the following life prolonging medical treatments:
																																																												
My personal, religious and spiritual care requests
If I am unable to communicate my wishes, please consider that I would want to receive the following care:

Specific Requests for Tissue, Organ and / or Body Donation (Please initial the small box that is next to the statement you are completing. Please cross out this section if you do not want to make a request)

☐ I have registered as an ORGAN AND TISSUE donor with Australian Organ Donor Register.            My organ donor registration number is: 							

I have discussed my organ and tissue donation wishes with my family and friends and they are aware of my decision  	YES / NO

I understand that my donation wishes may, in some situations, require the use of life sustaining treatment in an Intensive Care Unit.  I understand and accept that I may receive this additional care so my donation wishes can be carried out.

Body (Cadaver) and Other Donation
 
☐  I have registered as a cadaver / other donor. Please contact the following number to arrange            collection: 					

I understand that there may be specific instructions that need to be followed shortly after my death for cadaver and / or other body part donation to occur. I have discussed what needs to happen with my family / friends  YES / NO

Name:					 Signature:				 Date: Tuesday, 6th September 2016
or Proxy

Witness name:				 Signature:				 Date: Tuesday, 6th September 2016
 
Review date/s:			 			 			 			

Acknowledgement: Based on the Advance Care Planning template developed by Hunter New England Health Service 2011.