My Advance Care Plan (Page 2 of 2) in pdf

My Advance Care Plan Page 2

When I am dying, where practicable, I would prefer to be cared for at:

Initial the option you prefer

My usual home

A family member’s home

A hospice or palliative care unit

In hospital

On country (for Aboriginal and Torres Strait Islanders)

Other place

When I am dying, where practicable, I would like the following treatments:

Initial the option you prefer

Palliative Care

Stop medications which do not add to my comfort

Stop medical interventions which do not add to my comfort

Complementary and alternative therapies e.g.

Attend to my spiritual needs e.g.

I would like the following life prolonging measures, if practicable:

Initial the option you prefer

Revived if my heart and/or breathing stops

Artificial feeding

Intravenous fluids

Antibiotics

Intubation and ventilation

Blood transfusion and blood products

I have given a copy of my Advance Care Plan to:

Title

Full Name

Telephone

Mobile

Doctor

Hospital

Family

Friend

Other

I have also prepared the following to inform others about how to locate my Advance Care Plan

or other Advance Care documents e.g. AHD, Living Will, EPG:

¨ Medic Alert Bracelet

¨ Alert card in my purse/wallet

¨ eHealth record

¨ Other

Signed:

Date:

My Advance Care Plan Page 2