Advance Care Directive

Advance Care Directive
Any Advance Care Directive that you have previously made under this Act is automatically revoked (cancelled) when you complete and sign this Advance Care Directive.
Part 1

Personal details
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth*

DayMonthYear
Date
Phone Number*
Please enter a valid phone number.
Please list any major health conditions

Part 2

Values directive
Your medical treatment decision maker is legally required to first consider your values directive when making decisions about your medical treatment.

Identify who your medical treatment decisionmaker is and discuss your preferences and values with them. You can appoint someone using the Appointment of a medical treatment decision maker form. Refer to Part 2 of the instructions for more information. Please provide full details.
You may complete all, some, or none of the sections.
A) What matters most in my life
What does living well mean to you?
B) What worries me most about my future
C) For me, unacceptable outcomes of medical treatment after illness or injury are:
(For example, loss of independence, high-level care or not being able to recognise people or communicate)
D) Other things I would like known are:
E) Other people I would like involved in discussions about my care:
F) If I am nearing death the following things would be important to me:

Part 3

Instructional Directive
This instructional directive is legally binding and communicates your medical
treatment decision(s) directly to your health practitioner(s).

It is recommended that you consult a medical practitioner if you choose to complete this instructional directive.

·Your instructional directive will only be used if you do not have decision-making capacity
to make a medical treatment decision.

·Your medical treatment decisions in this instructional directive take effect as if you had consented to, or refused to, begin or continue medical treatment.

·If any of your statements are unclear or uncertain in particular circumstances, it will
become a values directive.

·In some limited circumstances set out in the Act, a health practitioner may not be required
to comply with your instructional directive.
a) I consent to the following medical treatment: (Specify the medical treatment and the circumstances).
b) I refuse the following medical treatment: (Specify the medical treatment and the circumstances).

You have reached the end of this form.
It is recommended that you review your advance care directive every two years, or whenever there is a change in your personal or medical situation.

· Please keep your original advance care directive safe and accessible for when it is needed.

· Ensure that your medical treatment decision maker (if any) has read and understood its contents.

Your advance care directive can be uploaded on MyHealth Record and should be shared with your medical treatment decision maker and relevant health practitioner(s) / health services(s).
Choose one

I am willing to be considered for organ and tissue donation, and recognise that medical interventions may be necessary for donations to take place.
I am NOT willing to be considered for organ and tissue donation.

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Any Advance Care Directive that you have previously made under this Act is automatically revoked (cancelled) when you complete and sign this Advance Care Directive.