My Advance Care Plan printable pdf download

My Advance Care Plan

Government of Western Australia

Department of Health

WA Cancer and Palliative Care Network

My Advance Care Plan

Last name:

First name:

Date of birth:

Address:

I have thought about what medical treatment will mean for me and have discussed it with my

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family, carers, and medical practitioners.

This plan reflects my wishes and details my goals for my treatment and care.

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If I am unable to speak for myself, I have nominated someone to speak on my behalf.

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Please use this plan to inform you about how I want to be treated if I can’t do so myself.

In addition to this Advance Care Plan, I have also completed an:

Advance Health Directive. A copy can be obtained from:

1. Name:

Telephone:

Mobile:

2. Name:

Telephone:

Mobile:

Enduring Power of Guardianship. A copy can be obtained from:

1. Name:

Telephone:

Mobile:

2. Name:

Telephone:

Mobile:

My life goals

These are my specific wishes about what I would like to achieve before I die.

My goals for treatment and care

These are my thoughts and feelings about my care towards the end of my life:

I would like to leave the following special message

This is a special message for:

My Advance Care Plan