My Advance Care Plan Page 3
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4Surname: ___________________________
First Name/s: ________________________
NHI Number: _________ DOB: __ / __ / __
Address: ___________________________
__________________________________
Phone: __________ Mobile: ____________
MY ADVANCE CARE PLAN
.
Please use this plan to inform my care only if I am unable to inform you directly
When I am dying the following are important to me
(tick):
Keep me comfortable
Take out tubes and lines that are not adding to my comfort
Let my family and friends be with me
Offer me something to eat and drink
Stop medications that do not add to my comfort
Attend to my spiritual needs
Other.................................................................................................................................................................
...........................................................................................................................................................................
The place I die is important to me
(tick):
Yes
No
When I am dying I would like to be cared for
(tick):
At home, which for me is:
..........................................................................................................................
In Hospice
In hospital
Other:................................................................................................................................................................
............................................................................................................................................................................
Please care for my body by ensuring the following:
I would like to be (tick):
Buried
Cremated
I would like the following as my end of life ceremony or funeral:
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
...........................................................................................................................................................................................
I would like to donate my organs and/or tissues for transplantation.
(tick):
Yes
No
Other
comments:..........................................................................................................................................................
...........................................................................................................................................................................................
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Parent category: Medical