Everyone desires autonomy in managing their health and making personal decisions. In the event of communication challenges, having a document is beneficial to guide our loved ones and healthcare professionals on how you wish your medical information to be conveyed.
Where I live is important to me: □ Yes □ No
I would prefer to be cared for:
□ At home, which for me is:…………………………………………
□ In hospital
□ In a hospital level care facility (residential care)
□ In a hospice
□ I don’t mind where I am cared for
□ I would like my EG/EPOA/ substitute decision maker to make this choice
You can legally appoint an Enduring Gauardian (EG)– This means they are legally involved however they are unable to make decisions for you until such a time when you are unable to make decisions for yourself-this advanced care directive can direct them in making decisions on your behalf
If for some reason you are unable to make a choice about your health, your appointed EG will be asked to make a decision. If you do not have one it is good to use this form to appoint a Substitute Decision Maker to help your health care team make the choices for you. If you choose not to appoint someone the medical professional will use this document as a guide regarding your wishes.
It is good when creating your plan to talk with your EG or appointed decision maker as you complete this form.
My Enduring Guardian (EG)/ Enduring Power of Attorney (EPOA)
Name: _______________________________________________________
Relationship to me______________________________________________
Phone: _______________________________________________________
OR
□ I do not have an EG/EPOA. I would like to appoint a substitute decision maker to use this ACP and make decisions for me if I am unable to make decisions.
Substitute decision maker:
Name: _______________________________________________________
Relationship to me______________________________________________
Phone: _______________________________________________________
□ The substitute person can make all decisions solely
OR
□ I request that the substitute decision maker discusses decisions with the following people:
Name: _______________________Relationship to me: ___________________
Phone: ___________________
Name: _________________________Relationship to me:_________________
Phone: _____________________