Professional Documents
Culture Documents
Advance Statement
Name:
Date: / /
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How does an Advance statement
help?
An advance statement lets everyone involved in your care know about your
wishes, feelings and preferences if you are not able to tell them.
Is an Advance statement
legally binding?
No, an advance statement is not legally binding, but anyone who is making
decisions about your care must take it into account.
More information about End of Life Care Planning can be found on the NHS website:
https://www.nhs.uk/conditions/end-of-life-care/
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Your details
Full name:
Preferred name:
Date of Birth: / /
Male Other
Transgender
Town or city:
Postcode:
Contact numbers: 1.
Please add phone
numbers that are useful 2.
for getting hold of you.
3.
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Your details
Lasting Power of Yes No
Attorney - Health
and Welfare
Lasting Power of
Name:
Attorney - Health
and Welfare details: Relationship:
Complete this section Contact number:
if answered ‘Yes’ to Email:
previous question
Name:
Relationship:
Contact number:
Email:
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In an emergency
Needs an Yes No
interpreter:
Preferred language:
Emergency contacts:
Name:
Relationship:
Contact number:
Email:
Name:
Relationship:
Contact number:
Email:
Pets: Yes No
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In an emergency
Pet details:
Name:
Complete this section
if answered ‘Yes’ to
Type of animal:
previous question What is important to know about your pet:
Name:
Type of animal:
What is important to know about your pet:
Home details:
Is there anything people
should know about your
home to help you in an
emergency?
Plan documents
location:
Where in your home will
you keep your care plan
documents?
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Your priorities of care
Current state of I am well with no illness
health:
I’m living with an illness
Other
State of health
Details:
Rank in order of
Maintaining comfort and being pain free
preference from 1 to 5. Sustaining my life even at the expense of
1: Most important comfort
5: Least important
1: Most important
4: Least important
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Your priorities of care
End of Life preferred Home
place:
Hospice
When you are
Hospital
approaching the end of
life, where would you Nursing home
prefer to be?
Rank in order of
preference from 1 to 4.
1: Most important
4: Least important
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If you lose capacity
Dietary None Halal
requirements: Vegetarian Other
You can make multiple
Vegan
selections
Kosher
Buddhist Muslim
Christian Spiritualist
Hindu Other
Humanist
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If you lose capacity
Spirituality Not at all Quite
importances: A little Very
Somewhat
Rituals:
Are there any religious
or spiritual rituals you
would like to include?
Other
Other
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If you lose capacity
Additional
information:
Is there anything else
your carers should know?
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About Amber Care Plans
Amber Care Plans is run by Digital Care Planning Limited, and is supported by SBRI Healthcare,
an NHS England initiative. We are based at St Mary’s Hospital, in London.
Our mission is to encourage more advance care planning so that healthcare can be aligned
with patients’ wishes. If you have any questions or quires about this document don’t hesitate
to contact us.
Contact us
W www.amberplans.com
E admin@amberplans.com
@ambercareplans
@ambercareplans
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Advance Care Plan
Advance Decision to Refuse Treatment
[ LEGALLY BINDING ]
Name:
Date: / /
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What is this document for?
This document should be completed by you or with your authorisation. It
states in advance any treatments you do not want in the future, under specific
circumstances.
If they have lost capacity, please check the validity and application of this ADRT.
If it is valid and applicative, please ensure that you act on it, as it is a legal
document. If it has not been signed or witnessed, then it is not legally binding
but should be used to help make decisions in the best interests of the patient.
Please help to share this information with relevant colleagues involved in their
treatment and care, who need to know about this.
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ADRT
Statement 1: If
Persistent
I am persistently unconscious
unconsciousness
A disorder of
And
consciousness, or there is little chance of recovery to a quality of life
impaired consciousness, that I would consider worthwhile (see ‘Quality of life
is a state where values statement’) in the opinion of two appropriately
qualified doctors
consciousness has been
affected by brain damage then
or injury.
I refuse all medical treatments aimed at prolonging or
artificially sustaining my life
If it is persistent then (including, but not limited to, CPR, ventilation, dialysis,
it means it has already antibiotics, clinically assisted nutrition such as feeding
been going on for several tubes, blood transfusions).
weeks and doctors
believe it won’t improve.
This includes persistent
vegetative states.
My signature
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ADRT
Statement 2: If I have any of the following:
Diagnoses
Severe head injury Heart failure
This is where you can
customise your wishes Lung failure Kidney failure
regarding specific
illnesses and diagnosis.
Terminal Cancer Dementia
Other
My signature
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ADRT
Statement 3: If I show any of the following:
Symptoms and
behaviours Persistently unaware of my surroundings
You can choose to leave then I wish to refuse the following treatments:
it out by crossing this
section off. All medical treatments aimed at prolonging or
artificially sustaining my life
OR
Cardio-pulmonary resuscitation (CPR)
Other
My signature
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ADRT
Quality of Life Values
Statement:
This is where you can
specify what quality
of life you consider
worthwhile. This will help
doctors to understand
and respect your wishes.
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ADRT
Quality of life values
statement:
[...] Feeding (do you want
to be able to swallow or
are feeding tubes okay?)
Communication (do
you want to be able to
communicate to have a
life worth living?)
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ADRT
For your ADRT to be legally binding you need to sign and witness it.
Sign and date this document and get a witness to sign too. They need to be over 18, and
should include their address in the space provided.
My signature
I confirm that the refusals of treatment in this
Advance Decision are to apply even if my life is
at risk or may be shortened as a result.
Name:
Date:
Signature:
Witness signature
Name:
Date:
Signature:
Address:
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About Amber Care Plans
Amber Care Plans is run by Digital Care Planning Limited, and is supported by SBRI Healthcare,
an NHS England initiative. We are based at St Mary’s Hospital, in London.
Our mission is to encourage more advance care planning so that healthcare can be aligned
with patients’ wishes. If you have any questions or quires about this document don’t hesitate
to contact us.
Contact us
W www.amberplans.com
E admin@amberplans.com
@ambercareplans
@ambercareplans
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