Advance Care Plan (ACP) Template

Personal Details: John Smith, born on 15 March 1950, is a 74-year-old male of British descent. Capacity and Consent: John has demonstrated full decision-making capacity and has consented to engage in advance care planning discussions. Understanding of Health Status: John understands his diagnosis of advanced chronic obstructive pulmonary disease (COPD) and acknowledges the progressive nature of his condition. He is aware of the potential need for increased medical support in the future. Personal Values and Beliefs: John values maintaining his independence and prioritizes quality of life over life-prolonging measures. He believes in the importance of dignity and comfort in his care. Goals for Future Care: John's primary goal is to remain as independent as possible while receiving care that maximizes his comfort and quality of life. Treatment Preferences: John prefers not to undergo resuscitation or mechanical ventilation. He is open to palliative care measures to manage symptoms. Preferred Place of Care: John wishes to receive care at home for as long as possible and prefers end-of-life care in a hospice setting if necessary. Substitute Decision-Maker(s): John has appointed his daughter, Emily Smith, as his substitute decision-maker. She can be contacted at 01234 567890. Family or Carer Involvement: John's family, particularly his daughter Emily, is actively involved in his care planning and decision-making process. Spiritual, Religious or Cultural Considerations: John identifies as agnostic and has no specific spiritual or religious considerations influencing his care preferences. Review Plan: The advance care plan will be reviewed annually or sooner if there is a significant change in John's health status. Emily Smith will initiate the review process. Clinician Details: Dr. Thomas Kelly, Psychologist, can be contacted at thomas.kelly@healthcareclinic.com.