Chcccs006 facilitate individual service planning and delivery

Age Care CertIV

Advance Care Plan Name: _____________________________________________________________

Address: ____________________________________________________________

Date of Birth: ____________________________________

If I cannot speak for myself, I would like my doctor to talk about my health care and medical problems to the following person/s: (please write their name and contact number/s) ____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________

I have legally appointed the following: Yes/No Name and contact number of person

appointed Enduring Guardian (Health decisions)

Enduring Power of Attorney (Money/finance decisions)

Who has copies of these legal documents? (please include contact number of person/s)

____________________________________________________________________________

____________________________________________________________________________

If I am very sick or badly injured, and others need to make medical decisions for me, please consider my following statements when making substitute decisions: The following things are important to me, and I want them to be considered in any decisions that are made on my behalf: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Cardio Pulmonary Resuscitation (CPR) (Initial the box that matches your choice) If my heart or breathing stops due to old age or irreversible (not curable) health problems my choice, if CPR is a treatment option, would be Please try to restart my heart or breathing (Attempt CPR)

Please allow me to die a natural death. Do not try to restart my heart or breathing (NO CPR) I cannot answer this question. Let my doctor decide. Signature: __________________________________ Date:

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Personal Values Please consider my personal values for the following statements if I am unable to make my own decisions in the future. (Put your initials in the box that is your response to each statement) I would find life to be acceptable OR difficult but bearable OR unbearable if, for the rest of my life:

Acceptable Difficult but bearable

Unbearable

I do not recognise my family and loved ones

I do not have control over my bladder and bowels

I cannot feed myself, and cannot wash myself, and cannot do my own personal grooming and dressing

I cannot move myself around in or out of bed and rely on other people to reposition (shift or move) me

I can no longer eat or drink and need to have food given to me through a tube in my stomach

I cannot talk, read and write

I can never have a conversation with others because I do not understand what people are saying

I do not get enjoyment from many of the things that I have always enjoyed

Talking about end of life:

Please initial the statement which is closest to your personal belief

I am frightened of dying and do not want to think about it happening to me or my loved ones. I do not discuss death or dying with others

Dying is a fact of life. You just have to deal with it when it happens. I hope that I can talk about it with loved ones and others before my time comes

Dying is a natural part of life. I am comfortable discussing death and dying with my loved ones and others. I want to be prepared for when my time comes

When my time for natural dying comes, if possible, I would like to be cared for At home or in a home like environment In a hospital or hospital like environment I do not know. I am happy for my family / person responsible to decide Signed:________________________________ Date: ___________ Review date/s: Witness signature___________________________ Date:_____________

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Additional optional page (not all people will want to include this page. Please staple to advance care plan if you wish this information to be included)

Name: ____________________________________________

Date of Birth: _______________________________________

Specific requests with regard to medical care (Please initial the box if you wish to identify specific treatment limitations. If you DO NOT have specific requests, please cross out this section)

I DO NOT WANT to have the following life prolonging medical treatments: _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

My personal, religious and spiritual care requests If I am unable to communicate my wishes, please consider that I would want to receive the following care: ___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

SPECIFIC REQUESTS FOR TISSUE, ORGAN AND / OR BODY DONATION (PLEASE INITIAL THE SMALL BOX THAT IS NEXT TO THE STATEMENT YOU ARE COMPLETING. PLEASE CROSS OUT THIS SECTION IF YOU DO NOT WANT TO MAKE A REQUEST)

I have registered as an ORGAN AND TISSUE donor with the Australian Organ Donor register. My organ donor registration number is _________________________________________________________

I have discussed my organ and tissue donation wishes with my family and friends and they are aware of my decision YES / NO I understand that my donation wishes may, in some situations, require the use of life sustaining treatment in an Intensive Care Unit. I understand and accept that I may receive this additional care so my donation wishes can be carried out. BODY (CADAVER) AND OTHER DONATION

I have registered as a cadaver / other donor. Please contact the following number to arrange collection _____________________________________________________

I understand that there may be specific instructions that need to be followed shortly after my death for cadaver and / or other body part donation to occur. I have discussed what needs to happen with my family / friends YES / NO ________________________________ ___________________________ Your Signature Date document signed ______________________________________ _________________________________ Witness signature Date witnessed

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Please use this page if you would like to provide additional specific direction or information regarding your choices for medical treatment or personal care if you are unable to speak for yourself.