York Teaching Hospital NHS Foundation Trust
Advance Care Plan A tool to help you plan for any future treatment and care
Your Name: Your NHS number:
For further advice, support or to obtain a copy of this plan in another format or language, please speak to the members of staff responsible for your care such as your doctors or nurses.
Our Values: Caring about what we do Respecting and valuing each other
Contents What is an Advance Care Plan?
2
Why should I do this?
2
How do I prepare my plan?
2
Who looks after my plan?
2
Will my choices be guaranteed?
3
Can I change my mind about what is included in my plan?
3
If I go into hospital should I take my plan with me?
3
Your Advance Care Plan Plan Consent Details (to be completed by health professional)
1
Page
4-8 9-10
Changes
11
Useful websites
12
Would you like to comment on this leaflet?
12
Teaching, training and research
13
Patient Advice and Liaison Service (PALS)
13
Caring with Pride: Our ultimate objective is to be trusted to deliver
Listening in order to improve Always doing what we can to be helpful
What is an Advance Care Plan? An Advance Care Plan is designed to help you plan for the future and record your preferences for the care you would, or would not like to receive, and where you would like to receive that care.
Why should I do this? You do not have to complete a plan but it might help to reassure you that your wishes will be known when care is planned. A plan would help the care professionals looking after you to try to meet your wishes.
How do I prepare my plan? A care professional will help you to prepare your plan and to record your wishes but you may want other friends or family to be involved as well. It is important that your views should be made clear to anyone acting on your behalf, including an appointed person with lasting power of attorney.
Who looks after my plan? Once the plan is prepared, it is yours to carry with you. If you need to see any care professional you can show it to them so that they will then have details of your illness and your wishes for any care.
safe, effective and sustainable healthcare within our communities
2
Our Values: Caring about what we do Respecting and valuing each other
Will my choices be guaranteed? Sometimes things can change unexpectedly, such as carers becoming over-tired or ill, or resources not being available to meet a particular need. Therefore while your choices cannot be guaranteed your wishes will always be taken into account.
Can I change my mind about what is included in my plan? Yes, you can change your plan at any time. Changes may relate to medication, details of treatment, or where you would like your care to be given. It is important that you discuss any changes with your care professional and that your plan is amended to show these changes.
If I go into hospital should I take my plan with me? Yes. Please show it to the doctor and nurse who admits you so that they know your wishes for your care. Ask them to return it to you as it is your plan and should remain with you.
3
Caring with Pride: Our ultimate objective is to be trusted to deliver
Advance Care Plan Patient Name:
NHS Number:
Address
Date of Birth
Religion
Phone Number
Next of Kin Contact Details
Phone number
GP Contact Details
Phone number
Relationship
4
Medical History Please give a brief history of the main diagnosis and history of your illness, including other significant medical problems
5
Advance Care Plan Patient Name:
NHS Number:
What discussions have taken place with you about where you would like to be cared for now and/or in the future?
Have you any particular thoughts about your care?
6
Advance Care Plan Patient Name:
NHS Number:
Is there any care or treatment you do/do not want to happen?
Have you any specific spiritual or religious needs?
7
Advance Care Plan signature section Patient Name:
NHS Number:
This form is an accurate record of my wishes Patient Signature
Date
Health Care Professionals completing this form Signature
Date
8
Plan Consent Details (to be completed by health professional)
9
Has the patient given consent for this plan to be discussed with his or her family? If so, please provide details.
Yes
No
Has the patient given consent for this plan to be discussed with his or her carer? If so, please provide details.
Yes
No
Plan Consent Details (to be completed by health professional) Has the patient given consent for this plan to be discussed with his or her lasting power of attorney? If so, please provide details.
Has the patient given consent for this plan to be discussed with other health/social care professionals?
Yes
No
Yes
No
A copy of this form should be sent to the GP and other relevant care professionals with the patient’s consent. 10
Changes Please record any changes to your wishes and preferences on this page. Please make sure that you discuss any changes with the care team. Changes Patient Name: Date and Change time
11
NHS Number: Sign
Listening in order to improve Always doing what we can to be helpful
Useful websites www.dyingmatters.org www.endoflifecareforadults.nhs.uk www.adrtnhs.co.uk
Tell us what you think We hope that you found this leaflet helpful. If you would like to tell us what you think, please contact: Kath Sartain, Macmillan Lead Cancer Nurse, Trust Headquarters, Scarborough Hospital, YO12 6QL or telephone 01723 236254.
safe, effective and sustainable healthcare within our communities
12
Our Values: Caring about what we do Respecting and valuing each other
Teaching, Training and Research Our Trust is committed to teaching, training and research to support the development of staff and improve health and healthcare in our community. Staff or students in training may attend consultations for this purpose. You can opt-out if you do not want trainees to attend. Staff may also ask you to be involved in our research.
Patient Advice and Liaison Service (PALS) Patients, relatives and carers sometimes need to turn to someone for help, advice or support. Our PALS team is here for you. PALS can be contacted on 01904 726262, or via email at
[email protected]. An answer phone is available out of hours.
13
Caring with Pride: Our ultimate objective is to be trusted to deliver
Listening in order to improve Always doing what we can to be helpful
safe, effective and sustainable healthcare within our communities
14
Providing care together in York, Scarborough, Bridlington, Whitby, Malton, Selby and Easingwold
Document produced in partnership with NHS, Social Services and voluntary organisations in North Yorkshire.
Owner Kath Sartain, Macmillan Lead Cancer Nurse January 2012 Date of Issue April 2018 Review Date 2 (reviewed and reissued May 2016) Version Layla Al-Ani, Lead Nurse, end of life care Approved By PIL 709 v2 Document Reference © 2016 York Teaching Hospital NHS Foundation Trust. All rights reserved.
www.yorkhospitals.nhs.uk
