Advanced Directive or Living Will
Power of Attorney
Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST) or
Physician Orders for Scope of Treatment (POST)
Complete Care Plan
Complete THIS FORM with the information
about the PERSON RECEIVING CARE
Caregiver Resources
Service Provided (Driving, adult day
car
e, meals, helpers, etc.)
Name of provider
or helper
Telephone
Advanced Care Planning**
Check the medical Advanced Care Planning topics that you have discussed with your health care provider:
This is a legal document (not a medical order), to appoint someone as your legal representative and provides instruc-
tions about how you wish to be treated and cared for at the end of your life. Because it is not a medical order, it is not
used to help doctors, emergency medical technicians, or hospitals treat you in an emergency.
This legal document is used for you to give a specific person the ability to make decisions for you when you are unable
to do so. It can be a spouse, adult child, family member, or friend. You can also name an alternate person in case
something happens to the primary person you name. The power of attorney is usually part of the Advanced Directive,
but is sometimes a separate document. Sometimes, depending on where you live, it is called a “medical (or healthcare)
power of attorney,” “medical proxy,” or “healthcare agent.”
This document, which varies by state, is a medical order signed by a medical professional and used for treatment. It is
generally used when a person is nearing the end of life, such as with a terminal or serious illness. This is a document
that your doctor can discuss with you during your Advanced Care Planning discussion. This does not name a “surro-
gate” or “medical proxy.” This document would be used together with the Living Will/Advanced Directive to guide your
loved ones and your doctors in the event that you are unable to make your own decisions
The following documents will be attached to this Care Plan:
Advanced Directive or Living Will
Power of Attorney
Orders for Life-Sustaining Treatment or Scope of Treatment
**Information provided by the American College of Physicians.
Plans for follow-up
Ask your medical provider to explain situations when you should call the doctor’s office, report to an emergency room,
or schedule a regular follow-up appointment. What are signs and symptoms you and/or your caregiver should look out
for? Make sure you write on a calendar all appointments for all caregivers to see.
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