FUTURE CARE PLAN

Name: DOB: 1
NORTH LINCOLNSHIRE LOCALITY
My
FUTURE CARE PLAN
Making plans for my care

 

Name: DOB: 2
INTRODUCTION
There may be times in your life when you think about the consequences
of becoming seriously ill or disabled. This may be at a time of ill health or
as a result of a life changing event. It may simply be because you are the
sort of person who likes to plan ahead.
You may want to take the opportunity to think about what living with a
serious or life limiting illness might mean to you, your partner or your
relatives, particularly if you become unable to make decisions for
yourself.
You may wish to record what your preferences and wishes for future
care and treatment might be or you may simply choose to do nothing at
all.
One way of making people aware of your wishes is by a process that is
called future care planning. This booklet is designed to help you write
your own future care-plan if that is what you wish to do – we hope that
you find it helpful. You may want family or those caring for you to help
record your preferences, however you should decide what is recorded.
This document is not legally binding. It provides you with the
opportunity to document your preferences, so that those caring for
you can take these into account.
You do not have to sign the document, or have it witnessed, however
your signature on the document helps make it clear whose views have
been recorded.
You can share this document with whom-ever you wish.
Remember this is your future care plan – you may not wish to answer
all of the following questions – you only have to complete the parts
that are important to you

 

Name: DOB: 3
There are a range of words used to describe care planning and decisions
and this section provides some useful definitions.
Care Plan
A general care plan that details the current and continuing health and
social care needs, achievable goals and actions required. A care plan is
generally written by health or social care staff, with input from the
individual. Not legally binding.
Future care plan/advance care plan
This can cover any aspect of future health and social care. It is written by
the individual, with support from others if needed. It covers the person’s
preferences, wishes, beliefs and values about future care. It guides
future decisions about best interests of the individual, if they lose the
capacity to make decisions. Not legally binding, but must be taken into
account when others are acting in the best interests of the person.
Advance decision to refuse treatment
This can only cover refusal of a specific treatment. It is made by the
person, who must have the capacity to make the decision, but may be
made with support from a clinician. It only covers refusal of future
specific treatment, in the event that the person loses the capacity to
make these decisions. This is legally binding if the decision is assessed as
complying with the Mental Capacity Act and provides legal and clinical
instruction to the multidisciplinary team.
For refusal of life sustaining treatment, it must be written, signed and
witnessed, and contain a statement that it applies even if the person’s
life is at risk.
Do not attempt cardiopulmonary resuscitation (DNACPR/DNAR)
This only covers decisions about withholding CPR. The form is completed
by a clinician responsible for the patient. It can be completed for a
person who does not have capacity if it is in their best interests. The
form is legally binding if it is part of an Advance Decision to refuse
treatment. Otherwise, it is advisory only and clinical judgement takes
precedence. This form does not need to be witnessed, but is usually
signed by the clinician. The decision can be reviewed and removed.

 

Name: DOB: 4
What is a future care plan?
Future care planning is about having conversations with your close
family, friends and care provider(s) so that they know your personal and
health care treatment wishes if you become incapable of expressing
your own decisions.
Writing down your beliefs, values and wishes for your future care is a
future care plan.
Developing your future care plan
Beliefs, Values and Wishes
Future care planning begins by thinking about your beliefs, values and
wishes regarding your health care and personal wishes, and talking
about them with family or friends, and your care provider(s).
The following questions may help you think about what is important to
you.
What are the things that make my life meaningful?
What is important to me?
Where would I like to be cared for in the last days of my life?
Who would I like to make decisions on my behalf if I am no longer able to
do so?
Have I put my affairs in order e.g. written a will?
What would I prefer not to happen?

When the people you trust know what is important to you with regard
to future health care and personal wishes, it is easier for them to make
decisions on your behalf.

Name: DOB: 5
An example of how Future Care Planning may help

Harry, 74, lives with his wife Beryl and she has recently been diagnosed
with dementia. Harry’s health has been poor for seven years. He has
kidney disease, diabetes and high blood pressure. He needs kidney
dialysis three times a week, and has congestive heart failure that
worsens every few months. He and Beryl live near their oldest son,
Paul, who helps with his care and goes to Harry’s doctor’s
appointments with him. Harry has three other children who live
nearby, and has a good relationship with all of them.
As Harry’s health is clearly declining, his doctor suggested he consider
writing a future care plan so that his wishes are known and it is clear
who will make decisions for Harry if he becomes incapable of deciding
for himself.
Harry talked with his wife and children, and identified that he would
prefer to stay at home to the end of his life, rather than in hospital or a
residential care facility. He has taken great pride in tending his garden
for the last 40 years and would like to be able to look out on it in the
last days of his life. He would like his wife and children to be with him
when he dies. He worries about being in pain, and would not want to
be hooked to machines to prolong his life.
Despite his health concerns, he would also like to be an organ donor if
possible.
He decides that he would like Paul to make decisions for him if he
becomes incapable of doing so. He has named Paul as the executor of
his will.

Name: DOB: 6
Putting your affairs in order
Future care planning is a good time to put all of your personal planning
papers together where they can be easily found.
These papers may include:
your will and the name of the executor
information about your organ donation wishes
insurance policies and any other financial arrangements you have
made.
other important documents, e.g. birth / marriage certificate(s)
The details of your funeral arrangements or burial plot if pre
planned/paid
your internet passwords (consider passing these to someone you
trust or changing important accounts while you are still able)
It is advisable to record in your future care plan where these papers are
kept; this will help those you have put in charge of your affairs to find
them if and when needed.
Changing your Future Care Plan
You can change your future care plan at any time – it is a document of
your wishes, beliefs and values.
As when writing the plan for the first time, it can be very helpful to
discuss any changes with the people that you trust; family or friends
and/or care providers.

 

Name: DOB: 7
Deciding where you wish to be cared for in the last days of your life
Some people feel sure about where they wish to be cared for in the last
days of their life, whilst others find it a very difficult topic to discuss or
make an informed decision about. It is also not uncommon for people to
change their mind as their illness progresses.
It is important to discuss this choice with your family/carers and the
professionals who are caring for you. Many people feel more
comfortable to make a preferred choice but to also have a back-up plan
to allow for anything unforeseen.
The professionals involved in your care will be able to discuss your
options with you and help you make an informed decision.
Planning Your Funeral
Many people now choose to plan their own funeral, often whilst still in
full health. The level of planning is entirely up to each person: for some
it is sufficient to say whether they wish to be buried or cremated; some
people just want to choose their own songs or hymns; others plan every
aspect of the service including choosing the celebrant, planning the
order of service and deciding on a dress code for everyone who attends.
Recording what kind of funeral you would like can be very helpful to
your family and friends. They are able to organise your funeral in the
knowledge and comfort that they are following your wishes and that the
service, whether very modern, very traditional or anything in between,
will reflect all of the things that are uniquely important to you.
Remember this is your future care plan – you may not wish to answer
all of the following questions – you only have to complete the parts
that are important to you

 

Name: DOB: 8
Date: My Future Care Plan
Update discussions
(use continuation sheet)

 

Date Update

 

Name: DOB: 9

 

Things that are important to me/ gives me quality of life
These religious or spiritual care needs are
important to me;
I am a registered as an organ donor Yes No
My wishes (for future care)
What would you really not want to happen
or fear happening?
Where I would like to be cared for during
my illness
My preferred place
If this is not achievable, I would like…

 

Name: DOB: 10

 

Where I would like to be cared for in the
last days of my life
My preferred place
If this is not achievable, I would like …
I would like these family members / friends
to be involved in my care if they wish
These are the things that I would take
comfort in (e.g. support for self and family,
pets, music, etc.)
I would like to make an Advanced Decision
to refuse treatment?
Please discuss this with your health care
professional. There is a separate booklet and
form to complete to help you identify any
treatments you may wish to refuse.
Yes No
I have written a will
My will is kept at …
Yes No
Is there any thing else that is important to you?

 

Name: DOB: 11

 

Who has been involved in your future care planning?
Next of Kin
Name
Contact details:
Relationship:
Name
Contact details:
Relationship:
Name
Contact details:
Relationship:
Name
Contact details:
Relationship:
Name
Contact details:
Relationship:
Name
Contact details:
Relationship:

 

Name: DOB: 12
Celebrating my life – My Funeral
What type of service would you like?

 

BURIAL OR CREMATION
Would you prefer a burial or cremation? Burial Cremation
Do you have a pre-paid funeral plan?
If yes, with which Funeral Director?
Policy Number
Yes No
If no, which Funeral Director would you like
to use?
Where would you like the service to take
place?
BURIAL
Do you have a family plot or have you
purchased a plot?
Where is the plot?
(please make sure that your next of kin or
executor knows where the paperwork for
this is kept)
Family Plot Own plot
If not, where would you like to be buried?
What style of headstone would you like?
CREMATION
Which crematorium would you like this to
take place?
What would like your family to do with your
ashes?

 

Name: DOB: 13

 

THE SERVICE
Do you have any specific instructions about
your funeral?
What does this include?
Do you want a religious service?
What religion are you?
Yes No I don’t mind
Who would you like to conduct the service?
Who would you like to take part in the
service?
What music would you like played?
Do you have anything that you would like
read at the service?
Would you like anything included in your
coffin? (some things cannot be included if
you have chosen to be cremated)
What would you like to be dressed in?

 

Name: DOB: 14
Please add any other information here.
If you want to let us know how helpful this form is, please tell us here

 

Would you like flowers or would you prefer
people to make a donation?
If a donation, where would you like the
donations to go to?
Flowers
Family Flowers only
Donations in lieu
None of the above

 

Name: DOB: 15
This document has been developed by patients, carers and staff within North Lincolnshire, based on North
East Lincolnshire Advance Care Plan