Get the free Advance Care Plan Form PDF 157KB - Department of Health - advancecareplanning org
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Government of Western Australia Department of Health WA Cancer and Palliative Care Network My Advance Care Plan Last name: First name: Address: Date of birth: I have thought about what medical treatment
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How to fill out advance care plan form
How to fill out advance care plan form?
01
Begin by gathering all necessary information and documents, such as personal identification, medical history, and any legal documents related to your healthcare preferences.
02
Start by providing your personal details, including your full name, address, contact information, and date of birth.
03
Specify your preferred language for communication and indicate whether you have any language or communication barriers that may impact your care.
04
Provide details about your healthcare proxy or durable power of attorney for healthcare, if applicable. This is the person who will make decisions on your behalf if you are unable to do so.
05
Outline your values, beliefs, and goals regarding medical treatment. Clearly state your preferences regarding life-sustaining treatments, resuscitation, and artificial nutrition and hydration.
06
Specify any treatments or procedures that you would like to receive or avoid, such as specific medications, surgeries, or interventions.
07
Include any specific instructions about pain management, comfort care, and end-of-life care, such as hospice or palliative care.
08
Indicate your preferences regarding organ donation and any specific instructions regarding funeral arrangements or burial/cremation preferences.
09
Review the form thoroughly for accuracy and completeness. Ensure that all sections are filled out properly and that your signature and date are included where required.
10
Make copies of the completed form and distribute them to your healthcare providers, family members, and anyone else involved in your care.
Who needs advance care plan form?
01
Individuals of all ages and health conditions can benefit from having an advance care plan form.
02
It is particularly important for those with chronic illnesses, terminal conditions, or elderly individuals who may be at higher risk of incapacitation or end-of-life decisions.
03
Caregivers, family members, and healthcare providers should also have access to the advance care plan form to ensure that the individual's wishes are respected and followed.
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What is advance care plan form?
The advance care plan form is a legal document that allows individuals to outline their preferences for medical treatment in case they become unable to communicate their wishes.
Who is required to file advance care plan form?
Any individual who wants to ensure their medical preferences are followed in case of incapacitation is required to file an advance care plan form.
How to fill out advance care plan form?
To fill out an advance care plan form, the individual must provide detailed instructions on their medical treatment preferences and appoint a healthcare proxy to make decisions on their behalf.
What is the purpose of advance care plan form?
The purpose of an advance care plan form is to ensure that an individual's medical treatment preferences are known and followed in case they are unable to communicate their wishes.
What information must be reported on advance care plan form?
The advance care plan form must include details on the individual's desired medical treatments, healthcare proxy designation, and any specific instructions for end-of-life care.
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