Advanced Directives

Form for an Advanced Directive

This form has twelve sections. You can print it and then take your time to fill it out.

  1. Personal details

Name:
Date of birth:
Address:
Home phone:
Mobile phone:
Email:
  1. Things that keep me well

There are some things we can do to help us stay well. List the things that you find important. For example:

  • Being with interesting friends and co-workers, and not isolating in my room
  • Getting up everyday, and being around people I like
  • Working at ______keeps me busy and out of trouble

These things keep me well:

  1. Things that make me unwell

Some things indicate when I am getting unwell. List the things that happen for you. For example:

  • Not taking my medications after going back home
  • Getting into a cycle where I work too much, get less sleep, become stressed and then manic, which turns into psychosis
  • Using too much alcohol/cannabis/weed/party drugs

These things indicate when I am getting unwell:

  1. Crisis symptoms

Some things make it obvious that we are very unwell. List what happens for you, so that if you are being seen by a Doctor who does not know you, they can assess whether you are in crisis. For example,

  • I shake all over, and I have had seizures
  • I give things away and have difficulty sleeping and eating, and have racing thoughts and become aggressive
  • I use alcohol/weed/other drugs all the time even though they make me crazy.

My crisis symptoms are:

  1. Emergency contacts

In emergency, please contact:

Name:
Relationship to me:
Contact details:

I would like the following family and/or friends to be involved in my care when I am unwell.

Name:
Relationship to me:
Contact details:
Name:
Relationship to me:
Contact details:

I do NOT want the following family members to be involved in my care when I am very unwell

Name:
Relationship to me:
Contact details:
Name:
Relationship to me:
Contact details:
  1. Enduring Power of Attorney

 I have given Enduring Power of Attorney to:

Name:
Address:
Phone:
Email:

That person can therefore, make decisions on my behalf if I am so unwell that I am not competent to express my wishes at the time.

OR

I have not given Enduring Power of Attorney to anyone.

  1. Treatments/CONSENT to

I CONSENT to the following treatments in a mental health crisis if I am not competent to express my wishes at the time.

TIP: If you Advance Directive is not used for several years, there may be new medications that your doctor will consider using. If you say why you consent to certain medications, and why you refuse others, it will help clinicians understand what you want.

Include as much information as you can. For example, ‘I see Doctor x at Clinic Y’ or ‘I use guided imagery for relaxation’ or ‘My tohunga/spiritual guide is Z, phone…’ You may want to list your treatment choices in order of preference. If you respond well to combined therapies, say so here.

Medication I CONSENT to

i. / Because
ii. / Because
iii. / Because

Other treatments I CONSENT to

 Resuscitation, because
 Electroconvulsive therapy (ECT) because
 Cultural services because
 Spiritual guidance or support because
 Other (give details below) because
  1. Treatments I REFUSE

I REFUSE the following treatments in a mental health crisis if I am not competent to express my wishes at the time.

TIP: If you Advance Directive is not used for several years, there may be new medications or other treatments that your doctor will consider using. If you say what you refuse certain medication and other treatments, it will help clinicians understand what you want.

For example:

Haloperidol – because it makes me stiff, I get blurred vision and I feel like a zombie.

Olanzapine – because it made my blood sugar go too high which was horrible and I do not want to risk diabetes.

Aropax – because it makes me try to kill myself.

Ativan – because I have had it before and I absolutely do not want any medication I could become addicted to.

Medication I REFUSE

i. / Because
ii. / Because
iii. / Because

Other treatments I REFUSE

 Resuscitation, because
 Electroconvulsive therapy (ECT) because
 Cultural services because
 Spiritual guidance or support because
 Other (give details below) because
  1. Validity of advance directive

This advance directive names the main health care choices I am making. I intend it to be used when I am not competent to make those choices, because of severe mental illness or distress.

  • I understand the consequences of this advance directive.
  • My treatment options, including likely benefits and risks, have been explained to me.
  • I have enough information to make choices about my mental health care.
  • I have made this advance directive of my own free will.

 This advance directive is to apply until (date) ______
OR
 This advance directive is to apply until I cancel it in writing.
If my doctor does not follow this advance directive, I want them to explain why, verbally and in writing, to:
 Me
 My family/whānau
 Other person
Name:
Address:
  1. Confirmation of competence

After printing your advance directive, discuss it with your doctor or nurse and ask them to complete this section below and sign it.

Name of doctor or nurse:
Position and organisation:
Contact details:
I confirm that is competent to make this advance directive, and s/he understands the consequences of this advance directive being followed.
Clinician’s signature:
Date:
  1. My signature - This document must be signed

Name:
Signature:
Date:
  1. Cancellation of advance directive

Don’t fill this section in now. If you want to cancel your advance directive later on, complete the section at that time.

This advance directive is cancelled from today, the (date)
I have made a new advance directive dated
OR
I have not made a new advance directive.
Signature:
Date: