- CREATE ACP{{ sectionCompletion(0) }}
- MY DETAILS{{ sectionCompletion(1) }}
- MY PRIORITIES FOR CARE{{ sectionCompletion(2) }}
- IF YOU LOSE CAPACITY{{ sectionCompletion(3) }}
- IN AN EMERGENCY{{ sectionCompletion(4) }}
- REFUSING TREATMENTS{{ sectionCompletion(5) }}
- CONFIRMATION{{ sectionCompletion(6) }}
CREATE ADVANCE CARE PLAN
Our easy questionnaire gives you a secure document of your wishes to share with your family and doctor.
MY DETAILS
MY PRIORITIES FOR CARE
1
I require the following things in order to live my minimum quality of life:
Choose as many as you like (these answers are ordered randomly each visit)
IF YOU LOSE CAPACITY
The next questions refer only to situations where you cannot speak for yourself and others have to make decisions about your medical treatment.
Rate each situation as if it was to occur within the next 12 months.
2
I cannot hear anything
3
I cannot see anything
4
I cannot talk to my loved ones, but I can hear them and understand what they say
5
I have mild to moderate pain and medication isn't helping
6
I have severe pain and medication isn't helping
7
I can only sleep for a few hours every night and medication isn't helping
8
I have persistent nausea and medication isn't helping
9
I cannot eat or swallow anything except sips of water
10
I have lost all control of my bladder
11
I have lost all control of my bowels
12
I am dependent on other people for all or most of my activities of daily living
Activities of daily living include eating, toileting, showering, dressing.
13
I am breathless for most of the day and medication is not helping
14
No-one is coming to visit me
15
My condition is impacting the lives of my loved ones and they are distressed by it
16
I do not recognise my family or my whereabouts
17
I need to be admitted to hospital for intravenous antibiotic therapy
IN AN EMERGENCY
The following questions address your medical intervention requests/preferences in case of a serious life changing issue, for example a stroke, heart attack, a complication in an operation, major accident or a deterioration in a major illness like widespread cancer.
Please select your preferred medical intervention for each question (notes can be added next to each question).
18
If I am in the same state of health and same quality of life that I have now and my heart stops beating causing me to stop breathing and have no pulse then:
19
If I suffer a catastrophic event like a stroke, a major accident, a complication in an operation or a major deterioration in my health causing me to stop breathing and have no pulse, then:
20
If I suffer a catastrophic event like a stroke, a major accident, a complication in an operation, or major deterioration in my health, and life sustaining treatment is available , then I agree to the treatments I have selected as YES and refuse the treatments I have selected as NO:
REFUSING FUTILE LIFE EXTENDING TREATMENT
21
Please note:
'Futile' medical treatment is treatment focused on extending your life but may not reduce your pain or symptoms.
Palliative Care is treatment focused on minimising your pain and symptoms rather than curing your illness or extending your length of life. Palliative treatments can still include medications, surgery and even radiotherapy to control and manage symptoms rather than extending life.
If my medical treatment is deemed ineffective (futile) and palliative care is available to manage my pain and symptoms then I choose the following:
22
If I have a terminal condition, I would prefer:
23
If I have a terminal condition, I would prefer to stay:
24
Are there any cultural, religious or family End-of-Life beliefs, customs and traditions that are important to you and your loved ones?
25
Are there any other messages, comments, explanations or directions you would like to make about your medical care to inform those who might have to make a decision on your behalf?
CONFIRMATION
If you are ready to complete your questionnaire, please complete all the following confirmation checkboxes.
We know life circumstances change. Therefore you will still be able to easily update, edit, or change your answers to this questionnaire at any time after pressing Finish.
PAPER DOWNLOAD
You may download a paper version of an Advance Care Plan here. This can be a useful tool to consider your answers in an offline environment, but we recommend returning to this site to enter your answers later. This will allow you and your emergency contacts to take advantage of easy online access.