Advance Care Planning

1. Choose your patient advocate.

Take time to think about who would be a good Patient Advocate for you. Your Patient Advocate is the person who can make medical decisions for you if you are unable to make them yourself. If 2 doctors decide that you cannot make your own medical decisions, they will ask that your Patient Advocate make them for you. Select someone you trust to make the decisions you would want. You may also name an alternate advocate to make the decisions if your first choice cannot. It is very important to have discussions about your wishes with your Patient Advocate.

• Your Patient Advocate can be a spouse or relative but doesn’t have to be – for some people, a friend, pastor or co-worker might be the right choice. (Your doctors, or any employees of your doctors or of the hospital you go to, usually cannot serve as your Patient Advocate.)
• Your Patient Advocate must be at least 18 years of age.
• They should be someone with whom you feel comfortable discussing your preferences, values, wishes and goals.
• They need to be willing to follow those preferences even if that is difficult or stressful and even if the decisions you would want made are different from the ones they would make for their own medical care.
• Your Patient Advocate must be willing to accept the significant responsibility that comes with this role. In sum, a good Patient Advocate must be able to serve as your voice and honor your wishes.

2. Instruct your patient advocate.

In order to serve you well and to be able to make the medical decisions you would want made, your Patient Advocate needs to know a great deal about you. The discussions between you and the person you choose to be your Patient Advocate will be unique, just as your preferences, values, wishes, goals, medical history, and personal experiences are unique.

Among the topics you might want to discuss with your Patient Advocate are:

• spiritual and religious beliefs, especially those that concern illness and dying
• experiences you have had in the past with family or loved ones who were ill
• fears or concerns you have about illness, disability or death
• your understanding of any medical conditions or diseases you have
• what gives your life meaning
• what sustains you when you face serious challenges

3. Sign the form & have it witnessed.

• You will need to sign and date the form in the presence of at least two witnesses.
• The witnesses must sign the form on the same date that you sign the form but only after you have signed it in their presence.
• Neither witness can be your Patient Advocate, spouse, parent, brother, sister, child, grandchild, heir, physician or employee of hospital.
• By signing the witnesses attest that they witnessed your signing the Patient Advocate form and that they believe you to be of sound mind and under no duress, fraud or undue influence.

4. Have your Patient Advocate sign the form.

Have your selected Patient Advocate and your Alternate Patient Advocate sign the DPOA-H legal form.

5. Turn in the form.

Once the DPOA-H form is completed, signed, and witnessed, please provide photocopies to your Patient Advocate, health care provider, family, and friends. Keep copies in an accessible place.