Free Advance Care Plan Template
Advance Care Plan
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Client Information |
Details |
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Patient Name: |
[Your Name] |
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Date of Birth: |
[Your DOB] |
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Address: |
[Your Address] |
I. Introduction
The Advance Care Plan (ACP) is a crucial document designed to ensure that your medical treatment aligns with your values and preferences, especially in scenarios where you may not be able to communicate your wishes due to illness or injury. Please carefully consider and complete the following sections to provide clear guidance to your healthcare providers and loved ones.
II. Personal Values and Beliefs
John Doe values quality of life over prolonging life through aggressive medical interventions. He believes in maintaining dignity, comfort, and autonomy throughout his healthcare journey. He prefers treatments that minimize pain and suffering and allow him to maintain communication and interaction with loved ones. John also holds strong spiritual beliefs and finds comfort in his faith.
III. Healthcare Agent
John Doe designates his spouse, Jane Doe, as his healthcare agent. He trusts her judgment and knows that she will advocate for his wishes in all medical situations. He has discussed his values and preferences with Jane extensively, ensuring she fully understands his desires regarding medical care.
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Name of Healthcare Agent: Jane Doe
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Relationship to John: Spouse
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Contact Information: 547-987-0583
IV. Goals of Care
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John Doe's primary goal of care is to maintain comfort and dignity, even if it means forgoing aggressive medical interventions.
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He values quality time with loved ones and wishes to ensure that his medical treatment allows for meaningful interactions.
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John emphasizes the importance of spending his remaining time with family and friends, creating lasting memories, and cherishing moments together.
V. Medical Interventions
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John Doe prefers a conservative approach to medical interventions.
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He wishes to avoid resuscitation in the event of cardiac arrest and does not want to be placed on mechanical ventilation or receive tube feeding.
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However, he is open to receiving pain management and palliative care to ensure comfort.
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John has documented his preferences regarding specific medical interventions in detail, providing clear guidance to his healthcare providers.
VI. Quality of Life
For John Doe, an acceptable quality of life includes the ability to communicate with loved ones, maintain cognitive function to a reasonable extent, and manage pain effectively. He values independence and autonomy but understands the importance of accepting assistance when necessary. John has discussed his definition of quality of life with his healthcare team, ensuring they understand his expectations regarding his medical care.
VII. Palliative Care and Hospice
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John Doe wishes to receive palliative care to manage symptoms and improve their quality of life if he is facing a serious illness or nearing the end of life.
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He is open to hospice care if his condition becomes terminal and prefers to spend his final days in the comfort of his home surrounded by loved ones.
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John has communicated his preferences regarding palliative care and hospice to his healthcare providers, ensuring they are prepared to provide him with the support he needs during challenging times.
VIII. Spiritual and Emotional Support
John Doe is a practicing Christian and would appreciate visits from a chaplain or spiritual counselor for emotional and spiritual support during times of illness or distress. He also values the support of his family and friends and wishes for them to be actively involved in his care. John has discussed his spiritual and emotional needs with his healthcare team, ensuring they are prepared to provide him with the support he needs to cope with his illness.
IX. Organ and Tissue Donation
John Doe has opted to donate his organs and tissues for transplantation or medical research purposes. He believes in the importance of giving the gift of life to others and hopes that his donation can make a positive impact on someone else's life. John has documented his decision to donate his organs and tissues in his advance care plan, ensuring his wishes are honored after his passing.
X. Additional Instructions
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John Doe requests that his healthcare providers and loved ones respect his wishes as outlined in this Advance Care Plan.
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He encourages open communication and dialogue about his medical treatment and values the input of his healthcare team in making informed decisions.
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John has provided additional instructions regarding his medical care, ensuring his wishes are communicated to his healthcare providers and loved ones.
XI. Signature and Witness
John Doe signs and dates the Advance Care Plan in the presence of a witness who is not his healthcare agent or a family member. The witness also signs and dates the document to confirm its authenticity.
[Your Name]
[Date]
XII. Witness
I, [Witness Name], confirm that I witnessed the signing of this Advance Care Plan by John Doe and that he appeared to be of sound mind and under no duress.
[Witness Name]
[Date]
