Getting To Know You

Start Info

Email On File with Us *

Todays Date *

Start Time *

Personal Profile

Patients Legal First Name *

Patients Legal Last Name *

Do you have a Patient Advocate? A patient advocate is a person you choose to make medical decisions for you if a severe illness or injury makes it impossible for you to speak or decide for yourself. *

Name of Advocate *

Relationship to client *

Understanding Their Values and What Matters Most

1. What is most important to you in your life right now?” *

2. What gives your life meaning or brings you joy? Are there certain activities, relationships, or experiences that you can’t imagine living without? *

3. How do you feel about your current health? Are there any concerns you’d like to address?

4. Have you ever experienced a difficult medical situation with a family member or friend? What did you learn from that experience?

5. Is there a medical scenario that would be completely unacceptable to you?

6. What fears or concerns do you have about your future medical situation? Check as many as appropriate for you.

7. Current level of health, what level of care would you prefer? choose one

Quality of Life Considerations

8. How true is this statement for you: "I value a better quality of life (even if shorter) vs. living longer through artificial life support."

9. In a situation where recovery was unlikely, how would you feel about life-sustaining treatments like a breathing machine or CPR?”

10. If Other Selected in question 9. Please explain here

11. 11. If there comes a time when I can no longer speak for myself, I want my healthcare team and my chosen advocate to be guided by what matters most to me. The situations below describe circumstances in which I feel that life would no longer be meaningful. In those cases, I would prefer to be kept comfortable and allowed to die naturally, without artificial life support. (check all that apply)

12. If Other Selected in question 11. Please explain here

Final Thoughts

Was this discussion helpful? *

Yes

Not Really

Do you feel better prepared to make future medical decisions based on our conversation? *

Name of those attending meeting *

Meeting Location *

The members of this meeting were given the opportunity to decline Advance Care Planning discussion and chose to move forward with the discussion. *

Yes

Reason for Consultation *

Was the Advanced directive Completed? *

End Info

End Time *

Total Time of ACP Consult *

Is this the Final Consultation *

Time of Second Apt *

Who is the facilitator? *