Advance Care Plan

Advance Statement

An advance statement is part of an advance care plan. It is a written

statement that sets down my preferences, wishes, beliefs and values
regarding my future care.

The aim is to provide a guide to anyone who might have to make

decisions in my best interests, if I have lost the capacity to make
decisions or to communicate them.

Name:

Date: / /

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How does an Advance statement
help?
An advance statement lets everyone involved in your care know about your
wishes, feelings and preferences if you are not able to tell them.

Is an Advance statement
legally binding?
No, an advance statement is not legally binding, but anyone who is making
decisions about your care must take it into account.

Who should see my Advance

statement?
You have the final say in who sees it. Keep it somewhere safe, and tell people
where it is, in case they need to find it in the future. You can keep a copy in your
medical notes, ask a GP to scan and upload it, or email them a copy.

More information about End of Life Care Planning can be found on the NHS website:
https://www.nhs.uk/conditions/end-of-life-care/
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Your details
Full name:

Preferred name:

Date of Birth: / /

Gender Female Prefer not to say

Male Other

Transgender

Primary address: Building and street:

Town or city:

Postcode:

Contact numbers: 1.
Please add phone
numbers that are useful 2.
for getting hold of you.
3.

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Your details
Lasting Power of Yes No
Attorney - Health
and Welfare

Lasting Power of
Name:
Attorney - Health
and Welfare details: Relationship:
Complete this section Contact number:
if answered ‘Yes’ to Email:
previous question

Name:
Relationship:
Contact number:
Email:

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In an emergency
Needs an Yes No
interpreter:

Preferred language:

Emergency contacts:
Name:
Relationship:
Contact number:
Email:

Name:
Relationship:
Contact number:
Email:

Pets: Yes No

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In an emergency
Pet details:
Name:
Complete this section
if answered ‘Yes’ to
Type of animal:
previous question What is important to know about your pet:

Name:
Type of animal:
What is important to know about your pet:

Home details:
Is there anything people
should know about your
home to help you in an
emergency?

Plan documents
location:
Where in your home will
you keep your care plan
documents?

Tip: Keep it in a bottle in

the fridge so paramedics
can find it. Also, write
down where other care
documents, and medical
information might be.

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Your priorities of care
Current state of I am well with no illness
health:
I’m living with an illness

I’m near the end of my life

Other

State of health
Details:

Future care Maintaining self awareness

priorities:
Being able to communicate with my family
What is the most
Being in my preferred place of care
important thing for you?

Rank in order of
Maintaining comfort and being pain free
preference from 1 to 5. Sustaining my life even at the expense of
1: Most important comfort
5: Least important

Preferred place of Home

care:
Hospice
Where would you prefer
Hospital
to be cared for if your
health deteriorated? Nursing home
Rank in order of
preference from 1 to 4.

1: Most important
4: Least important

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Your priorities of care
End of Life preferred Home
place:
Hospice
When you are
Hospital
approaching the end of
life, where would you Nursing home
prefer to be?

Rank in order of
preference from 1 to 4.

1: Most important
4: Least important

Other care priorities:

Write your priorities for
the last months, weeks
or days of life. Include
anything you think might
be useful for your carers
to know.

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If you lose capacity
Dietary None Halal
requirements: Vegetarian Other
You can make multiple
Vegan
selections
Kosher

Allergies or None Nuts

intolerances: Gluten Soya
You can make multiple
Eggs Other
selections
Dairy

Food and drink likes: Breakfast:

Lunch and dinner:

Food and drink

dislikes:

Faith or value: Atheist Jewish

Buddhist Muslim

Christian Spiritualist

Hindu Other

Humanist

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If you lose capacity
Spirituality Not at all Quite
importances: A little Very

Somewhat

Rituals:
Are there any religious
or spiritual rituals you
would like to include?

This can be important

religious or other beliefs,
or anything that makes
you feel happy and
content

Activities: Listen to Music

If you have to stay in bed Read
for a prolonged period
of time, what would you
Watch TV
prefer to do? Use personal computer / tablet

Other

Sleep: Leave lights on

What helps you sleep Complete darkness

well?
Some light

Background music / radio

Other

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If you lose capacity
Additional
information:
Is there anything else
your carers should know?

You can include:

Likes: for example

hobbies and interests,
how I like to relax and
what reassures me e.g.
talking to someone on a
one-to one or in groups,
music or TV

Dislikes: for example

crowds or noisy places,
sitting in the sun or I
don’t like animals

Personal care: shower

or bath? Wet shave or
dry? Also, I prefer to be
dressed rather than wear
pyjamas - no nylon.

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About Amber Care Plans
Amber Care Plans is run by Digital Care Planning Limited, and is supported by SBRI Healthcare,
an NHS England initiative. We are based at St Mary’s Hospital, in London.

Our mission is to encourage more advance care planning so that healthcare can be aligned
with patients’ wishes. If you have any questions or quires about this document don’t hesitate
to contact us.

Contact us

W www.amberplans.com

E admin@amberplans.com

@ambercareplans

@ambercareplans

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 Advance Care Plan
Advance Decision to Refuse Treatment

[ LEGALLY BINDING ]

An Advance Decision to Refuse Treatment is part of an Advance Care

Plan. It is a written statement which details specific treatments that I do
not want to have in certain situations. It is legally binding, if it is signed
and witnessed.

This Advance Decision to Refuse Treatment is intended to apply

indefinitely unless I specifically revoke it.  I give permission for anyone
legitimately involved in my care to read it.

Name:

Date: / /

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What is this document for?
This document should be completed by you or with your authorisation. It
states in advance any treatments you do not want in the future, under specific
circumstances.

Advice to anyone reading

this document:
Please do not assume the person who completed this document lost capacity
to make decisions or to communicate. They may need help and time to
communicate.

If they have lost capacity, please check the validity and application of this ADRT.
If it is valid and applicative, please ensure that you act on it, as it is a legal
document. If it has not been signed or witnessed, then it is not legally binding
but should be used to help make decisions in the best interests of the patient.

Please help to share this information with relevant colleagues involved in their
treatment and care, who need to know about this.

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ADRT
Statement 1: If
Persistent
I am persistently unconscious
unconsciousness
A disorder of
And
consciousness, or there is little chance of recovery to a quality of life
impaired consciousness, that I would consider worthwhile (see ‘Quality of life
is a state where values statement’) in the opinion of two appropriately
qualified doctors
consciousness has been
affected by brain damage then
or injury.
I refuse all medical treatments aimed at prolonging or
artificially sustaining my life
If it is persistent then (including, but not limited to, CPR, ventilation, dialysis,
it means it has already antibiotics, clinically assisted nutrition such as feeding
been going on for several tubes, blood transfusions).
weeks and doctors
believe it won’t improve.
This includes persistent
vegetative states.

You can choose to leave

this statement out by
crossing this section off.

Include the above statement in my ADRT

My signature

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ADRT
Statement 2: If I have any of the following:
Diagnoses
Severe head injury Heart failure
This is where you can
customise your wishes Lung failure Kidney failure
regarding specific
illnesses and diagnosis.
Terminal Cancer Dementia

A disease of the central nervous system

Tick one or more of the
options on the right Other
to add items to your
statements or simply
and I develop an illness that is in need of urgent
care with little chance of recovery to a quality of
type your wishes in the
life which I consider worth while
‘other’ box.

then I wish to refuse the following treatments:

You can choose to leave
it out by crossing this
section off.
OR
All medical treatments aimed at prolonging or
artificially sustaining my life
Cardio-pulmonary resuscitation (CPR)

Treatments designed to maintain or replace a

vital bodily function (such as a ventilation or
dialysis)
Antibiotics given for a potentially life-
threatening infection
Clinically assisted nutrition (feeding tubes)
Blood product transfusions

Other

Include the above statement in my ADRT

My signature

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ADRT
Statement 3: If I show any of the following:
Symptoms and
behaviours Persistently unaware of my surroundings

Persistently unable to recognise loved ones

This is where you
can customise your Persistently unable to communicate with others
wishes regarding Persistently unable to attend to my personal
specific symptoms and hygiene
behaviours.
Persistently unable to swallow food
Tick one or more of the
Persistently anxious or agitated
options on the right
to add items to your Other
statements or simply
type your wishes in the and there is little chance of recovery to a quality
‘other’ box. of life that I would consider worthwhile

You can choose to leave then I wish to refuse the following treatments:
it out by crossing this
section off. All medical treatments aimed at prolonging or
artificially sustaining my life
OR
Cardio-pulmonary resuscitation (CPR)

Treatments designed to maintain or replace a

vital bodily function (such as a ventilation or
dialysis)
Antibiotics given for a potentially life-
threatening infection
Clinically assisted nutrition (feeding tubes)
Blood product transfusions

Other

Include the above statement in my ADRT

My signature

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ADRT
Quality of Life Values
Statement:
This is where you can
specify what quality
of life you consider
worthwhile. This will help
doctors to understand
and respect your wishes.

You can use the following

questions as a guide
for writing your values
statement:

1. What are your end of

life goals and priorities?
What does a good death
look like? What would
you like to happen?

2. What are your fears or

worries about the end of
your life?

3. What end of life

outcomes are acceptable
/ unacceptable to you?

4. What would a good

day look like?

Take into consideration:

Mobility (walking, getting

around with or without
help) [...]

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ADRT
Quality of life values
statement:
[...] Feeding (do you want
to be able to swallow or
are feeding tubes okay?)

Awareness (do you want

to be aware of your
surroundings, or who
you are with?)

Communication (do
you want to be able to
communicate to have a
life worth living?)

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ADRT
For your ADRT to be legally binding you need to sign and witness it.
Sign and date this document and get a witness to sign too. They need to be over 18, and
should include their address in the space provided.

My signature
I confirm that the refusals of treatment in this
Advance Decision are to apply even if my life is
at risk or may be shortened as a result.

Name:
Date:
Signature:

Witness signature
Name:
Date:
Signature:
Address:

Health or social care

Name:
professional details
Job title:
Contact details:

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About Amber Care Plans
Amber Care Plans is run by Digital Care Planning Limited, and is supported by SBRI Healthcare,
an NHS England initiative. We are based at St Mary’s Hospital, in London.

Our mission is to encourage more advance care planning so that healthcare can be aligned
with patients’ wishes. If you have any questions or quires about this document don’t hesitate
to contact us.

Contact us

W www.amberplans.com

E admin@amberplans.com

@ambercareplans

@ambercareplans

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