Sie sind auf Seite 1von 3

ADVANCE CARE PLAN

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

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).

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 I
may need long team, ongoing supportive care and medical treatment for the
rest of my life.

I request life prolonging treatment that will support (help) me to recover and
live 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 a
way that is meaningful to me, then I request only medical treatment that will
promote 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, make


the medical treatment decisions that they feel are in my best interests. I want
them to know that their decisions will be the right decisions for me.

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 _____________