Help You Manage Your Health and Care As Well As Possible

My Dementia Care Plan

My Dementia Care Plan aims to:

· Help you manage your health and care as well as possible

· Helps you and the medical professionals, i.e. doctors and nurses, and others who may be involved with your care to work together with you to know about your health condition(s) and what is important to you.

· Provide information about your condition, your medication and your preferences in a convenient form which can be available should you need to visit a hospital or a surgery other than your usual one (e.g. who do not have access to your GP notes)

· Help everyone involved in your health to know what your goals are over the next 12 months.

Created:

Printed

About Me

My Name: / What I like to be called:
Address: / DOB:
Who lives at home:
Work: (Circle one )
I am working full time / part time / unemployed / sick leave / retired
Contact Details:
Phone:
Mobile:
Email: / Preferred means
of contact: / Communication needs:
Religion / Ethnic Background: / My preferred language is:
My NHS number: / GP Name, Address , Tele number

My next of kin and other contacts:

Name / Relationship to me / Contact details
Next of kin:

My main carer/supporter and others involved in my care (if appropriate):

Name / Relationship to me / Contact details
Main carer/supporter:
This is the care my carer provides to me:
These are the services my carer accesses for support / e.g. Carer’s in Herts or Crossroads
Tips for talking to me

My Choices

The following section is for you to write information about yourself, your likes and dislikes and what is important to you. It is up to you whether you wish to complete this and how much information you want to include. Some people have found this helpful particularly when meeting new staff and professionals in the community.

You may also like to include information on your dislikes and what is important to you for the people supporting you to understand.

My background, skills and interests
Things I like and dislike
How you can help me do the things I like

My Safety

Areas of high risk for me:
What you must do to keep me safe:

My Personality

How I am generally as a person, my disposition:
How I respond to new situations and difficulties
What upsets me
How can you support me to be positive and help me when I am distressed or withdrawn:

My Cognitive Ability

How dementia has affected my thinking and doing:
What I can still do:
What I find difficult:
How you can help me to do the things I can still do and support me with the things I find difficult:

My past and how it affects me

What is important for you to know about my past
How my past affects the way I am today
How you can support me to make the best use of my past and overcome any difficulties it causes for me
What is important for you to know about my cultural and spiritual background
How you can support me to maintain my cultural identity
What you need to know about my use of language

My Physical Health

What I can still do for myself:
What I find difficult
How you can help me with my physical health.

My Sensory Impairment

My good senses are
What I find difficult
How you can help me to make best use of my senses

My Eating and drinking habits

Things I like
Things I do not like
This is how and where I prefer to eat
These are things I must have
How you can help me with eating and drinking

My Environment

The environment that suites me best is:
These are the challenges I have
This is how you can support me to make the best of the world around me

My Social Network

People and organisations which are important to me
How you can support me with maintaining these relationships
How you can support them to maintain a relationship with me
How I like to be around others and how I like others to be around me

Your Services and Support

Service
e.g Physiotherapy / Name
e.g. Debbie Smith
When
e.g. Mondays from 1/3/10 at 2pm / Support
e.g. Mobility exercises
Service / Name
When / Support
Service / Name
When / Support
Service / Name
When / Support

My Appointments List
You may find it helpful to make a note here of your appointments. Record below who the appointment is with and the date, time and venue.

Date / Time / Where / Who with

My Medication

(You may wish to attach a list of your current medications to this care plan. Please ask your pharmacist or GP to provide you with a recent copy).

Medication / Dose / Format eg. tablet, syrup, injection / type of device etc / I take this medication at the following times / I take this medicine because it will ( eg. help prevent me from having a heart attack)

My allergies and drug reactions are:

Drug Name / Reaction (e.g. rash or diarrhoea)

This is the support I need with managing my medicines:

Concerns I have about my medication that I want to discuss with my doctor:

Date of last review: Date of next review:

Questions I want to ask my health professional at my next appointment and other relevant information:

Concerns I have about my diagnosis and health in the future:

What do I do if I become poorly?

(sudden change in my health)

Signs and symptoms / Action to be taken / Who to contact? / Contact details

Advance Planning: If my condition progresses or suddenly deteriorates, these are the arrangements that I would like to be considered:

My preferences and priorities for future care when I am ill or towards the end of life:

Treatment Escalation Plan
Preferred Place of Care
Treatment Escalation Plan
DNARCPR Status

I can confirm I have the following documentation:

Document / Yes / No / Where these documents are kept
Advance Directive/Living Will
Lasting Power of Attorney(Finances)
Lasting Power of Attorney (Welfare)
Do Not Attempt Cardiopulmonary Resuscitation Order signed by a doctor
Other Care or Support Plan

My healthcare team (list key people)

Name of person/organisation / How they will/can help me? / Contact details
Care Coordinator
GP
Nurse
Optician
Pharmacist
OT/ Physiotherapist
Dentist

This shared care plan was created by me/ in partnership with me (*delete as appropriate) and reflects my personal information, wishes, needs and goals.

Completed By:

Signature:
Date:

Additional Information

For further Information on a range of other support services I can contact Herts Help on 0300 123 4044 (Mon – Friday 8am-6pm)

http://www.hertsdirect.org/your-community/ihertshelp/

NHS Choices: good place to start when looking for trusted health information. http://www.nhs.uk/pages/home.aspx

My Advance Decision to Refuse Treatment

This is my Advance Decision to Refuse Treatment in which I am specifying in advance which treatments I do not want in the future, should I lose mental capacity and can no longer consent to or refuse treatment.

This Advance Decision to Refuse Treatment replaces any previous advance decision I have made

I wish to refuse the following specific treatments which may or may not be life sustaining even if my like is at risk / In these circumstances

Record of discussion

Name: Date of Birth:

Details of the discussion:

Statement of Intent

I being of present mind; wilfully and voluntarily execute this Advance Decision to Refuse Treatment, to assure that, during periods of incapacity, my choices regarding my health care will be carried out despite my inability to make informed decision on my own behalf. I intend this document to take precedence over all other means of ascertaining my intent during such periods of incapacity.

To the extent, if any, that this document would not be considered valid in law, it is my desire that it is considered a statement of my wishes, and that it is accorded the greatest possible legal weight and respect. Understand that this decision will become active and take effect upon my incapacity.

Any blanks in this document should not affect its validity in any way. I intend all completed sections are followed.

I am aware that this Advance Decision to Refuse Treatment will be valid from the date of signing. I will be given the opportunity to renew, amend or cancel it one year from now. If I am incapacitated at this time, then my Advance Decision to Refuse Treatment will remain in place until I become well enough to make decision.

I may withdraw this decision at anytime by notifying my doctor or health and social care professionals in writing of my intention to do so.

My signature Date:

I confirm that this form has been completed by the above named person and I am acting as a witness to their signature

Witness

Name: / Signature / Date:
Address:
Telephone: / Mobile:

Person to be contacted to discuss my wishes

Name:
Relationship
Address:
Telephone:

I have discussed this with (name of health professional)

Name:
Job title:
Telephone:
Email:

I give permission for this to be discussed with my relatives YES NO

(please tick)

People who have been told about this Advance

Decision to Refuse Treatment

The following list identifies people who have been given a copy of this Advance Decision to Refuse Treatment.

Please write in the names and contact details of people who have been told about this Advance Decision to Refuse Treatment, and have been given a copy.

Name / Relationship / Address / Telephone