My Care Plan

Personal Information
Name	
	
Address	
	
DOB	
	
GP Details	

Next of Kin/Lasting Power of Attorney
Who would you like to be consulted if it ever became difficult for you to make decisions or in the case of an emergency?
If you have officially appointed someone to make decisions on your behalf, using a Lasting Power of Attorney (LPA) for health and welfare, please indicate this below.  This is difference to a LPA for financial affairs.
Name 		
Address		
Tel number		
Relationship		
Do they have LPA for health and welfare?               Yes                             No	

Name 		
Address		
Tel number		
Relationship		
Do they have LPA for health and welfare?               Yes                             No	

My future care
Where would you like to be cared for if you become unwell and unable to look after yourself, e.g. stay at home, move into sheltered or other supported accommodation, residential care or a nursing home?
My first choice:		
My second choice 		

Please turn over
What are your wishes and preferences for your future care?
What would be important for people to know if you were not able to communicate, e.g. food/drink preferences, hygiene (bath/shower/shave/hair/make up), sleep (preferred times for getting up/going to bed, light on /off, windown open/closed) and hobbies/interests.  What would give you a good quality of life?

Is there anything you worry about or fear happening?

Do you have concerns about practical issues e.g. who will look after your child/pet?

Do you have any thoughts about how much active treatment you would want to receive at this stage?

Advance decisions to refuse treatment.
Have you made an advance decision to refuse treatment with your GP known as a living will or advance directive?
Yes 					No
If yes please give details of where this is kept below and give a copy to your healthcare professionals.

Organ Donation
Are you on the NHS Organ donor register? 		Yes		No
Comments:
	
For more information and about organ donation ring 0300 123 23 23 or go to www.organdonation.nhs.uk
For more information about donating your body to London medical and dental schools see:
www.kcl.ac.uk/biohealth/study/departments/anatomy/lao/index.aspx 	

Completion
Details of the person completing this form:
Name	
	
Signature	
	
Date		

Reviews
It is advised that your review your plan regularly and document any changes to your wishes.

Please ensure this document is easily accessible to those who need to refer to it and you have shared your wishes, preferences, and plans to those important to you.

Please also share a copy with your GP and any other health or social care professional involved in your care.