Create your free Advance Care Plan

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CREATE ADVANCE CARE PLAN

Our free, easy questionnaire gives you a secure document of your wishes to share with your family and doctor.

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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)

Other:

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

Life is not worth living Not sure Life is still worth living
3

I cannot see anything

Life is not worth living Not sure Life is still worth living
4

I cannot talk to my loved ones, but I can hear them and understand what they say

Life is not worth living Not sure Life is still worth living
5

I have mild to moderate pain and medication isn't helping

Life is not worth living Not sure Life is still worth living
6

I have severe pain and medication isn't helping

Life is not worth living Not sure Life is still worth living
7

I can only sleep for a few hours every night and medication isn't helping

Life is not worth living Not sure Life is still worth living
8

I have persistent nausea and medication isn't helping

Life is not worth living Not sure Life is still worth living
9

I cannot eat or swallow anything except sips of water

Life is not worth living Not sure Life is still worth living
10

I have lost all control of my bladder

Life is not worth living Not sure Life is still worth living
11

I have lost all control of my bowels

Life is not worth living Not sure Life is still worth living
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.

Life is not worth living Not sure Life is still worth living
13

I am breathless for most of the day and medication is not helping

Life is not worth living Not sure Life is still worth living
14

No-one is coming to visit me

Life is not worth living Not sure Life is still worth living
15

My condition is impacting the lives of my loved ones and they are distressed by it

Life is not worth living Not sure Life is still worth living
16

I do not recognise my family or my whereabouts

Life is not worth living Not sure Life is still worth living
17

I need to be admitted to hospital for intravenous antibiotic therapy

Life is not worth living Not sure Life is still worth living

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:



* Note: Review your answers to minimum quality of life in question 1.
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:

* Note: Review your answers to minimum quality of life in question 1.
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 only the treatments I have selected as YES and refuse the treatments I have selected as NO:

Breathing machine (ventilator)
Artificial feeding tube into the stomach (PEG)
Artificial feeding tube through the nose (Nasogastric tube)
Kidney machine (dialysis)
Blood transfusions
Operations
In hospital intravenous antibiotic therapy

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.

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