Advance Care Plan A tool to help you plan for any future treatment and care

Your Name: Your NHS number:

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.

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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.

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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

Medical History Please give a brief history of the main diagnosis and history of your illness, including other significant medical problems

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?

Is there any care or treatment you do/do not want to happen?

Have you any specific spiritual or religious needs?

The above is an accurate record of my wishes Patient Signature Date

Health Care Professionals completing this form Signature Date

Plan Consent Details 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

Yes

No

Yes

No

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?

A copy of this form should be sent to the GP and other relevant care professionals with the patient’s consent.

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 time

NHS Number:

Change

Sign

Would you like to comment on this leaflet? Meeting the needs and preferences of patients and carers is at the centre of everything we do. We hope that you found this leaflet useful and informative. If you would like to comment on it, please contact: Kath Sartain, Specialist Macmillan Nurse, St Catherine’s Hospice, Throxenby Lane, Scarborough, YO12 5RE or telephone 01723 356043.

Teaching and Training York Teaching Hospital NHS Foundation Trust is involved in the teaching or training of medical staff who may be in attendance at some patient consultations. However, there is an 'opt out' option for any patient who prefers to see a doctor without training medical staff in attendance.

Patient Advice and Liaison Service (PALS) Patient Advice and Liaison Service (PALS) is located in the main entrance of The York hospital. They can be contacted on telephone number 01904 726262, answer phone is available out of hours or via email at [email protected].

This plan is available in other formats and languages. If you require this leaflet in Braille, on audio tape or CD, in large print or another language please telephone 01904 725796. 8

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Our Commitment to You Our ultimate objective is to be trusted to deliver safe, effective healthcare to our community. You can find further details on our website: www.york.nhs.uk.

Useful websites:www.dyingmatters.org www.endoflifecareforadults.nhs.uk www.adrtnhs.co.uk

For further advice or support please speak to the members of staff responsible for your care such as your doctors or nurses.

Document produced in partnership with NHS, Social Services and voluntary organisations in North Yorkshire.

Owner Date of Issue Review Date Version Approved By

Kath Sartain Specialist Macmillan Nurse January 2012 January 2014 1 (issued January 2012) Maggie Draper Deputy Directorate Manager Adult Community Services

© 2012 York Teaching Hospital NHS Foundation Trust All rights reserved

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