My name: NHS number: Date of birth: My preferred place of care Who will explain my wishes I have a Lasting Power of I have an Advance Attorney for Health Decision to Refuse and preferences to health At home Treatment care professionals if I am Not at home unable to? Yes No Yes No (Named Spokesperson) (Care home) Name: It can be found: preferred place of care Carer’s At home Contact tel: Not at home Contact tel: Planning (Care home) Signature: Date: Date completed: I have decided to review this plan on: Should I lose the ability to make decisions, I give permission for this information to be shared with other relevant health & social care for professionals. Family members or those identified as important to the patient involved in this Future Care Planning discussion: Name: Relationship: Signature: Contact tel: your Name: Relationship: Signature: Contact tel: future Name: Relationship: Signature: Contact tel: Healthcare Professionals involved in this Future Care Planning discussion: Name: Role: care Signature: Contact tel: Name: Role: Signature: Contact tel: If there is a medical treatment that you to happen you may need to make an Advance Decision to Refuse Treatment don’t want Advance care planning framework 2015-18, appendix C, p27 Adapted from West Lancs, Southport & Formby Advance Care Plan
My name: Date of birth: NHS number: Planning for your future care My preferred place of care At home Not at home (Care home) Who will explain my wishes and preferences to health care professionals if I am unable to? (Named Spokesperson) I have a Lasting Power of Attorney for Health Yes No I have an Advance Decision to Refuse Treatment Yes No Name: It can be found: Carer’s preferred place of care At home Not at home (Care home) Contact tel: Contact tel: Signature: Date: Date completed: I have decided to review this plan on: Should I lose the ability to make decisions, I give permission for this information to be shared with other relevant health & social care professionals. Family members or those identified as important to the patient involved in this Future Care Planning discussion: Name: Relationship: Signature: Contact tel: Name: Relationship: Signature: Contact tel: Name: Relationship: Signature: Contact tel: Healthcare Professionals involved in this Future Care Planning discussion: Name: Role: Signature: Contact tel: Name: Role: Signature: Contact tel: If there is a medical treatment that you don’t want to happen you may need to make an Advance Decision to Refuse Treatment Advance care planning framework 2015-18, appendix C, p27 Adapted from West Lancs, Southport & Formby Advance Care Plan