Advance Care Planning (QMS-F066) ADVANCE CARE PLANNING (QMS-F066) Subscribe Document Ref: QMS-F066 (Advance Care Planning) Version: 1.0 Confidentiality Level: HIGH (Medical / Legal Records) CQC Alignment: Responsive (End of Life Care) Service User Full NameService User ID NumberOperating Local Authority- Select -HaringeyIslingtonWaltham ForestBarnetCare Funding & Financial Arrangements- Select -Local Authority Managed (Direct Commissioning)NHS Funded (Continuing Healthcare - CHC)Direct Payments (Personal Budgets)Self-Funded (Full Cost)OtherSECTION 1 - Resuscitation Status (DNACPR & ReSPECT)Cardiopulmonary Resuscitation (CPR) Status- Select -For Full Resuscitation (No DNACPR in place - dial 999 and initiate CPR)Valid DNACPR is physically present in the property (Do NOT initiate CPR)Valid ReSPECT form is physically present in the propertyAwaiting GP confirmation of status (Treat as 'For Resuscitation' until confirmed)If a DNACPR/ReSPECT is in place, has the assessor physically seen the original, signed document?Help Message: A photocopy is generally not valid for emergency services. The original must remain with the service user.Yes, visually verifiedNo (Treat as 'For Resuscitation' until physically verified)Exact Location of DNACPR/ReSPECT Document in the HomeMandatory Emergency Protocol I confirm that care workers will be instructed: If the original DNACPR cannot be found during an emergency, they MUST dial 999 and commence CPR immediately.SECTION 2 - Advance Directives & Legal AuthorityDoes the service user have an Advance Decision to Refuse Treatment (ADRT / Living Will)?- Select -YesNoADRT DetailsLegal Representation for Health & Welfare- Select -Service User retains full capacity for health decisionsRegistered Lasting Power of Attorney (LPA) for Health & WelfareCourt Appointed Deputy (Health & Welfare)Independent Mental Capacity Advocate (IMCA) appointedSECTION 3 - End of Life PreferencesPreferred Place of Care / Death (PPC/PPD) Their own home A specific Hospice Hospital A Nursing Home Undecided / Not discussed yetSpiritual, Religious, or Cultural PreferencesSECTION 4 - Care Worker Instructions & Sign-offExpected vs. Unexpected Death ProtocolAssessor NameDate of AssessmentSave Advance Care Plan
