ADVANCE CARE PLANNING NOTE

Patient: [Name]
Date of birth: [Date]
Date: [Date]
Setting: [Clinic, hospital, home, care home, or video]
Start and end time: [Times, and total minutes in the conversation]
Clinician: [Name, credentials, role]

WHO TOOK PART
Present: [Patient, family, decision-maker, interpreter, and team members, with relationship or role]
By phone or video: [Names, or none]
Why now: [Planned visit, new diagnosis, decline, hospital stay, upcoming surgery, or the patient's request]
Patient agreed to: [Who could be present, and what could be shared with them]

CAPACITY
For these decisions: [Has capacity, lacks capacity, or it varies, and how you judged it]
If the patient lacks capacity: [Who spoke for the patient, on what authority, and what is known of the patient's own past wishes]
Communication: [Language, interpreter, hearing or vision aids, written materials given]

UNDERSTANDING OF ILLNESS
In the patient's words: [What they understand about their illness and where it is heading]
Information wanted: [How much they want to know, and who they want included]
What was shared: [Diagnosis, likely course, and outlook as discussed, with the uncertainty named]
Response: [Emotions, questions, and what they took away]

WHAT MATTERS MOST
Goals and values: [What matters most now, and if their health gets worse]
Fears and worries: [What they fear most about the future]
Abilities they can't imagine living without: [What makes life worth living for them]
Trade-offs: [What they would and wouldn't go through for the chance of more time]
Faith, culture, and family: [Beliefs or traditions that shape their choices]

DECISION-MAKER
Substitute decision-maker or health care agent: [Name, relationship, phone]
Alternate: [Name, relationship, phone, or none]
How named: [In a legal document, or by the default order where you practice]
Knows and agrees: [Whether the decision-maker knows their role and has heard the patient's wishes]
Leeway: [Follow these wishes closely, or room to decide in the moment]

TREATMENT PREFERENCES
Resuscitation if the heart stops: [CPR, or no CPR, and the reasons]
Breathing machine and intensive care: [Wanted, a time-limited trial, or not wanted]
Hospital transfer: [For any problem, for some problems only, or comfort care where they live]
Artificial nutrition and fluids: [Feeding tube or IV fluids: wanted, a trial, or not wanted]
Other treatments: [Dialysis, antibiotics, transfusion, an implanted defibrillator, or others discussed]
Overall focus of care: [Full treatment, selective treatment, or comfort-focused care]
Recommendation: [What you recommended, and why]

DOCUMENTS
Advance directive: [Completed, updated, reviewed, or none, and where the original is kept]
Portable medical order: [POLST, MOLST, or the order used where you practice, with its choices; or not indicated, and why]
Resuscitation order: [Do-not-resuscitate order written, confirmed, or not written]
Goals-of-care designation: [The designation recorded, where your organization uses one]
Old documents: [Replaced or voided, or none]
Copies to: [Patient, decision-maker, hospital, specialists, care home, and where the original is kept]

PLAN
Next steps: [Forms to finish, people to talk to, and referrals such as palliative care]
Review: [Date, or after a change in health, a hospital stay, or a new diagnosis]

Signed: [Clinician name, credentials, date and time]