PACT EOLC Personal Plan

Thinking ahead

This form is designed to help you to consider what is important to you in your future care and to communicate that to your GP. If you have already had these conversations with another health professional, please don’t feel obliged to complete these sections but let your GP know.

Care Planning Consultation
PATIENTS NAME: DATE OF BIRTH:
GP.……………………………………………………………………………………………………………………………………………………….
Next Appointment Date Time

Please bring this to your appointment as it will be used to record what you would like to discuss at your review and its outcomes.

These are some of the things which people ask about.
Circle/comment on any which are most relevant to you?
Medical check ups / Your mood and any worries you have;
Have you been feeling depressed or alone?
Taking medication / What supports you/ comforts you when you are feeling worried?
Medical/physical side effects from medication / Problems at home (cleaning/shopping) or finances? Worries about your family? Pets?
Immunisations / Difficulty sleeping?
Should I expect to have pain? Will I be given medication for this? / Sexual health
How to manage loss of appetite and weight loss / Information about the services available to me?
Mobility/ Independence/ Falls / The future, what is likely to happen?
What aspects of your medical condition(s) would you like to discuss?
In relation to your health, what has been happening to you?
What are your wishes, beliefs, values and feelings about your illness.
What are your preferences and priorities for your future care?
Do you understand the types of care or treatment that are available and their benefits, harm and risk?
At this time in your life what is it that makes you happy and/or you feel is important to you?
What elements of care are important to you and/or what would you like to happen in future?
What would you NOT want to happen? Is there anything that you worry about or fear happening?
Are there any other issues which are important to you?
If your condition deteriorates where would you most like to be cared for?
1st Choice
2nd Choice
Comments
Do you have any special requests, preferences or comments?
Are there any comments or additions from other people you are close to?
Access…. Have you considered
Who has spare key?
Pendant/ call alarm?
Key safe?
Do you have a living will or legal advance decision document?
Yes: who has a copy?
Proxy/ next of kin
Do they have official Lasting Power of Attorney (LPoA) Registered with Office of Public Guardian?
Contact 1: Tel:
Relationship: LPoA:
Contact 2: Tel:
Relationship: LPoA:
Who else would you like to be involved if it ever becomes difficult for you to make decisions or if there is an emergency?
Finances
Are you paying all your bills ok? Do you have a will? Do you know if you are getting all your benefits?