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My Advance Care PlanMy Wishes and Preferences
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My Advance Care Plan
WhatisthisPlanfor?ThePlancanhelpyouprepareforthefuture.Itgivesyouanopportunitytothinkabout,talkaboutandwritedownyourwishesandpreferencesforcareinthefutureandattheendofyourlife.ThePlancanhelpyouandyourcarers(yourfamily,friendsandprofessionals)tounderstandwhatisimportanttoyouwhenplanningyourcare.Ifatimecomeswhen,forwhateverreason,youareunabletomakeadecisionforyourself,anyonewhohastomakedecisionsaboutyourcareonyourbehalfwillhavetotakeintoaccountanythingyouhavewritteninyourPlan.Sometimespeoplewishtorefusespecificmedicaltreatments inadvance.ThisPlanisnotmeantto be used for such legally binding refusals. If you decide that youwant to refuse anymedicaltreatments, youmaydo sousingadocument calledan ‘AdvanceDecision toRefuseTreatment’whichyouwillneedtodiscusswithyourdoctors.Rememberthatyourviewsmaychangeovertime.Youcanchangewhatyouhavewrittenwheneveryouwishto,anditwouldbeadvisabletoreviewyourPlanregularlytomakesurethatitstillreflectswhatyouwant.
WhatshouldIincludeinmyPlan?Youshouldincludeanythingthatisimportanttoyouorthatyouareworriedabout.Itisagoodideatothinkaboutyourbeliefsandvalues,whatyouwouldandwouldnotlike,andwhereyouwouldliketobecaredforattheendofyourlife.
Willmywishesandpreferencesbemet?Whatyouhavewritten inyourPlanwillalwaysbe taken intoaccountwhenplanningyourcare.However, sometimes things can change unexpectedly (like carers becoming over-tired or ill), orresourcesmaynotbeavailable tomeetaparticularneedor thehealth condition thatyoumaydevelopandcouldmakeithardtofollowyourwishesentirely.
ShouldItalktootherpeopleaboutmyPlan?You may find it helpful to talk about your future care with your family and friends, althoughsometimesthiscanbedifficultbecauseitmightbeemotionalorpeoplemightnotagree.Itcanalsobeusefultotalkaboutanyparticularneedsyourfamilyorfriendsmayhaveiftheyaregoingtobeinvolvedincaringforyou.Yourprofessionalcarers(likeyourdoctor,nurseorsocialworker)canhelpandsupportyouandyourfamilywiththis.Whenyouhave completedyourPlanyouareencouraged tokeep itwithyouand share itwithanyoneinvolvedinyourcaree.g.yourGPandotherhealthandsocialcarestaffaswellasyourfamilyand/orthoseclosetoyou.Unlesspeopleknowwhatisimportanttoyou,theywillnotbeabletotakeyourwishesintoaccount.
My Advance Care Plan
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Personalinformation
Name
Address
DOB
GPDetails
Nextofkin/Lastingpowerofattorney
Whowouldyouliketobeconsultedif iteverbecomesdifficultforyoutomakedecisionsorinthecaseofanemergency?
Ifyouhaveofficiallyappointedsomeonetomakedecisionsonyourbehalf,usingaLastingPowerofAttorney (LPA) for health and welfare, please indicate this below. This is different to a LPA forfinancialaffairs.
Name
Address
Tel.No
Relationship
DotheyhaveLPAforhealth&welfare?
Yes☐
No☐
Name
Address
Tel.No
Relationship
DotheyhaveLPAforhealth&welfare?
Yes☐
No☐
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MylifestoryAbriefsummaryofimportantthingsyouwouldlikepeopletoknowaboutyou–family,home,placeswhere you have lived,working life, retirement, current and past interests. Youmay alsowish toattachacouplephotosofyourself,asyoulooknowandonefromyourpast.
ThepresentA brief description of your current situation, problems, difficulties or concerns (includinggenerallevelsofhealthandability).
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MyfuturecareWherewouldyou like tobecared for if youbecomeunwellandunable to lookafteryourselfe.g.stay at home, move into sheltered or other supported accommodation (private flat with sharedfacilitiesandawarden),residentialcare(homefor long-termcare)ornursinghome(carehomewithnursingcare)?
Myfirstchoice:
Mysecondchoice:
Comments:
Whatareyourwishesandpreferencesforyourfuturecare?
Whatwould give you a good quality of life?What do you like?What are your hobbies andinterests?What’simportanttoyou?
What are your food/drink preferences, hygiene (bath/shower/shave/hair/make-up), sleep(preferredtimesforgettingup/goingtobed,lighton/off,windowopen/closed)?
Isthereanythingyouworryaboutorfearhappening?Doyouhaveconcernsaboutpracticalissues(whowilllookafteryourchild,pet…)?
Doyouhaveanythoughtsabouthowmuchactivetreatmentyouwouldwanttoreceiveatthisstage?
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MyendoflifecareWhenyoureachtheendofyourlifewherewouldyouliketobecaredfore.g.athome,carehome,hospitalorhospice?
Myfirstchoice:
Mysecondchoice:
Comments:
Whatwouldbeimportanttoyouasyouapproachtheendofyourlifeanddoyouhaveanyspecificwishesforthistime?
Whowouldyouliketobewithyou?Howwouldyoulikethingstobe?
Isthereanythingyouworryaboutorfearhappening?
Isthereanythingthatmaycomfortyoue.g.music,smells,photos?
Whatareyourthoughtsaboutpaincontrol?
Doyouhaveanythoughtsaboutactivetreatmentatthisstage?
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Pleasegivedetailsbelowofanypeopleyouwouldliketobecontactedattheendofyourlife,whocouldinformothersofyourdeathandpossiblyyourfuneralifyouarehavingone.
Name:
Relationship:
Telephone:
Address:
Name:
Relationship:
Telephone:
Address:
Name:
Relationship:
Telephone:
Address:
MyspiritualCare
Doyouhaveaparticularfaithorbeliefsystemthatisimportanttoyou?
Howwouldyoulikethistobetakenintoaccountattheendofyourlife?
Pleasegivedetailsbelowofanypeopleyouwouldliketobecontactedattheendofyourlife,whocouldinformothersofyourdeathandpossiblyyourfuneralifyouarehavingone.
Name:
Relationship:
Telephone:
Address:
Name:
Relationship:
Telephone:
Address:
Name:
Relationship:
Telephone:
Address:
MyspiritualCare
Doyouhaveaparticularfaithorbeliefsystemthatisimportanttoyou?
Howwouldyoulikethistobetakenintoaccountattheendofyourlife?
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AdvancedecisionstorefusetreatmentHaveyoumadeanAdvanceDecision toRefuseTreatmentwithyourGP (previouslyknownasaLivingWillorAdvanceDirective)?
Yes☐ No☐
Ifyes,pleasegivedetailsofwherethisiskeptbelowandgiveacopytoyourhealthcareprofessionals:
Funeralwishes
Iwishtobe:Buried☐ Cremated☐
Haveyouapre-paidfuneralplan(tocoverthecostofyourfuneral)? Yes☐ No☐
Ifyes,pleasegivedetailsincludingproviderandpolicynumberandwherethesearekept:
Haveyourecordedyourfuneralwishes? Yes☐ No☐ Wishesyoumayhaveforyourfuneral:
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Will
HaveyoumadeaWill? Yes☐ No☐ Ifyes,whereistheWillheld?
Organdonation
AreyouontheNHSOrgandonorregister?Yes☐ No☐Ifyes,pleaseaddyourNHSOrgandonornumber:_______________________________________
Comments:
Formoreinformationaboutorgandonationring03001232323orwww.organdonation.nhs.uk
For more information about donating your body to London medical and dental schools seewww.kcl.ac.uk/biohealth/study/departments/anatomy/lao/index.aspx
Furtherinformation
Doyouhaveanyfurthercommentsorwishesthatyouwouldliketosharewithothers?
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Completion
Detailsofthepersoncompletingthisform:
Name:
Signature:
Date:
ReviewsItisadvisedthatyoureviewyourplanregularlyanddocumentanychangestoyourwishes.YoucanrecordanychangesintheAddendumsectionbelow.
Pleaseensurethisdocumentiseasilyaccessibletothosewhoneedtorefertoitandyouhavesharedyourwishes,preferencesandplanswiththoseimportanttoyou.
PleasealsoshareacopywithyourGPandanyotherhealthorsocialcareprofessionalinvolvedinyourcare,andyourfamilyand/orthoseclosetoyou.
AddendumPleaseusethisspacetorecordanychangestoyourPlan.RemembertosignanddatethesechangesandtosharethemwiththosewhoalreadyholdacopyofyourPlanaswellasyourGPandanyoneelseinvolvedinyourhealthandsocialcare.
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