Advance Care Plan Form
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1
2ADVANCE CARE PLAN
Instructions: Competent adults and emancipated minors may give advance instructions using this form or any form of their own
choosing. To be legally binding, the Advance Care Plan must be signed and either witnessed or notarized.
I, ____________________________________, hereby give these advance instructions on how I want to be treated by
my doctors and other health care providers when I can no longer make those treatment decisions myself.
Agent: I want the following person to make health care decisions for me:
Name:
_____________________________
Phone #: _____________
Relation: _____________________
Address: ____________________________________________________________________________________
Alternate Agent: If the person named above is unable or unwilling to make health care decisions for me, I appoint as
alternate:
Name:
_____________________________
Phone #: _____________
Relation: _____________________
Address: ____________________________________________________________________________________
Quality of Life:
I want my doctors to help me maintain an acceptable quality of life including adequate pain management. A quality of
life that is unacceptable to me means when I have any of the following conditions (you can check as many of these
items as you want):
Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of
ever waking up from the coma.
Permanent Confusion: I become unable to remember, understand or make decisions. I do not recognize loved
ones or cannot have a clear conversation with them.
Dependent in all Activities of Daily Living: I am no longer able to talk clearly or move by myself. I depend on
others for feeding, bathing, dressing and walking. Rehabilitation or any other restorative treatment will not help.
End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment. Examples:
Widespread cancer that does not respond anymore to treatment; chronic and/or damaged heart and lungs, where
oxygen needed most of the time and activities are limited due to the feeling of suffocation.
Treatment:
If my quality of life becomes unacceptable to me and my condition is irreversible (that is, it will not improve), I direct
that medically appropriate treatment be provided as follows. Checking “yes” means I WANT the treatment.
Checking “no” means I DO NOT want the treatment.
CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it
has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.
Yes No
Life Support / Other Artificial Support: Continuous use of breathing machine, IV fluids,
medications, and other equipment that helps the lungs, heart, kidneys and other organs to continue to
Yes No
work.
Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a
new condition but will not help the main illness.
Yes No
Tube feeding/IV fluids: Use of tubes to deliver food and water to patient’s stomach or use of IV fluids
into a vein which would include artificially delivered nutrition and hydration.
Yes No
PLEASE SIGN ON PAGE 2
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Parent category: Medical