Important Documents

“You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die.” – Dame Cicely Saunders

Advanced Care Planning

Advanced Care Planning is the process by which you begin to think about, talk about and document your wishes for future healthcare. These documents can be used by your family and healthcare team to guide your care if you get sick or you are at the end of your life.

Three forms are included in Advanced Care Planning:

  1. Goals of Care Designation Order
  2. Tracking Record
  3. Personal Directive

These forms are all contained in what is called “A Green Sleeve.’ This sleeve should be kept in a common area, like on your fridge, so if Emergency Medical Services needs to come to your home they can easily access it.

Goals of Care Designation Order

This is a medical order from your doctor that lets healthcare practitioners know what your wishes are when they are deciding on healthcare interventions and future care. Your doctor/Nurse Practitioner will speak with you and/or your ‘agent’ who is a person you choose to make decisions on your behalf. Your doctor/Nurse Practitioner will speak with you to better understand your healthcare goals and who you are as a person. They will then write your Goals of Care Designation as a medical order. When our order is made you will have a decision to make about three general approaches to care. Within each approach there is also a number (1-3) assigned.

Medical Care (M)

This is for when you choose to have medical tests and interventions to cure or manage an illness but do not want resuscitative or life support measures used.

Resuscitative Care (R)

This is for when you choose to have any medical or surgical intervention, including resuscitative and life support measures, to sustain your life.

Comfort Care (C)

This is for when you choose not to have any resuscitative or life support measures in addition to medical or surgical interventions to treat an illness. Instead, the focus is on alleviating symptoms. This is for people who have a life-limiting illness and medical treatments cannot change its course.

Tracking Record

Your decisions about your care may change over time. This is a piece of paper used to keep a record of conversations about your Advanced Care Plan with your healthcare provider.

Personal Directive

A personal directive is a legal document that states one or two people, also called ‘agents,’ that you choose to make decisions on your behalf. This is for if you become incapacitated by illness or injury and are unable to voice your wishes. In this document you can also state under which circumstances this person(s) can make decisions.

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