What matters to me: my wishes for my future care
Your Advance Care Plan from Royal Trinity Hospice
A useful planner for Trinity patients, those closes t to them or anyone looking to plan their future
What this book is for Page 3
Your health Page 5
Preferences for your future care Page 7
Your life Page 11
Planning your funeral Page 14
Legal and financial documentation Page 20
Legacies Page 21
Insurance policies Page 26
Utilities Page 27
Documents Page 28
Your life online and social media Page 29
What is this book and who is it for?
Some of us find it comforting to know our wishes for the future are recorded and can be easily found when needed. It can feel especially reassuring for those living with life-limiting or serious illness, to plan for the future.
Thinking ahead and writing down what matters to you can be a daunting process. However, if no one else knows what is important to you, your preferences and choices may not be taken into consideration. It may be difficult to talk together with your family and you may not always agree, but having these conversations can help direct decisions that sometimes need to be made at a time of crisis. You may also like to talk to someone in your healthcare team. You have the right to do this in confidence and independently of friends and family if you wish.
At Royal Trinity Hospice, we openly talk about issues relating to death and dying and this includes encouraging people to plan ahead, and spend time thinking about their plans without feeling rushed. This planner, which may also be referred to as an advance care plan , covers a range of personal , medical , financial and domes tic matters and can be used to share information with those important to you as your illness advances. It helps to tell someone you trus t where this book is s tored.
It is important to note that this book is not a legally binding document and can be changed or altered at any time. There is information throughout , signposting you to places that can help you prepare legal instruction. Support is available through Royal Trinity Hospice so please ask anyone working for the hospice if you would like additional help or advice.
Do not include any details such as passwords or pins for accounts, as these should remain totally confidential.
Completing this book
This book has been designed for patients receiving care and support at Trinity to use, but in reality, anyone can use it.
You can fill in as much or as little information as you wish , at your own speed. While you may choose to complete the entire book , you may prefer only to fill in sections that matter to you, or you feel able to complete. You may wish to work through this book at the same time as a friend or family member so you can discuss your wishes and talk through your answers together
The specialis t s taff at Royal Trinity Hospice can help with many of the aspects of completing this book. Please ask us if you would like to be put in touch with someone
Your name:
Any previous names or aliases:
Your preferred pronouns:
Your address:
Pos tcode:
Your date of birth: Your NHS number:
The date of completion of this book:
This book is intended for you to share with family, friends, or those closest to you, to give you peace of mind that your wishes have been recorded.
We do however strongly encourage all patients to complete a Universal Care Plan so your preferences for your future health care are shared with all professionals involved in your care now, and in the future.
Please speak to any Trinity health care professional about how to create a Universal Care Plan or find out more at ucp.onelondon.online
Your health
Name and address of your GP:
Pos tcode:
Your NHS number (can be provided by your GP):
Details of your next of kin / a person who knows you well
Their relationship to you:
Their name:
Their address:
Pos tcode:
Their contact number:
Have you completed a Universal Care Plan? Yes No (please select) If yes, where is it s tored?
Have you had a conversation with your doctor or a member of the team at Royal Trinity Hospice about a DNACPR form (stands for ‘Do Not Attempt Cardiopulmonary Resuscitation’)? Yes No (please select)
If so, have you completed one?
Key contacts related to your health:
Your District Nurse
Name:
Address:
Contact numbers (working and out of hours):
Your care manager / agency name
Name:
Address:
Contact numbers (working and out of hours):
Pos tcode:
Pos tcode:
Contact details for other people involved in your care such as physiotherapist, pharmacist etc
Name:
Their relationship to you:
Name:
Their relationship to you:
Name:
Their relationship to you:
Contact number:
Contact number:
Contact number:
Preferences for your future care
If you were no longer able to care for yourself what would you like to happen?
This section gives you the option to consider who you would like to care for you, and where you would ideally like to receive care.
Writing down your preferences and choices can help you to influence what happens to you if you are no longer able to communicate your wishes. Some of the ques tions in this section could help health care professionals know what is important to you when planning your care, should you be unable to tell them yourself
Remember, this is not a legally binding document , but can help ensure that decisions about your treatment and care are carried out according to your wishes.
Who is your current primary care giver / contact? If you like, you can provide two names:
Name:
Their relationship to you:
Name:
Their relationship to you:
Contact number:
Contact number:
If you were unable to communicate your wishes in relation to your care and treatment , who would you want to do so on your behalf?
Name:
Address:
Their relationship to you:
Pos tcode:
Contact number:
Appointing a Las ting Power of Attorney (LPA) can bring peace of mind when considering what you would want to happen if you los t capacity to make decisions for yourself, in relation to health and financial matters.
For more information on LPAs, please see Royal Trinity Hospice’s free leaflet at www.royaltrinityhospice.london/lpa
Have you formally appointed a Las ting Power of Attorney (LPA)?
Yes / No (please circle)
If you have, please provide your Trinity nurse with a copy to be scanned and held with your patient notes.
Your Lasting Power of Attorney
Name:
Address:
Pos tcode:
Contact number:
Is this las ting Power of Attorney for:
Property and affairs Personal welfare Both
If you have online access to the UK Government ’s Las ting Power of Attorney Service, you can reques t an access code to allow others to view your LPA. Further information can be found at www.gov.uk/view-las ting-power-of-attorney
Appointing a Las ting Power of Attorney can take several weeks (or even months) and is worth considering when arranging your affairs.
Below you can provide a lis t of people who you are happy for us to share information with in relation to your health and care
Do you have any additional communication needs e.g. glasses or hearing aids? Or do you require the use of a sign language interpreter or translator?
Yes No (please select)
If yes, please lis t:
If you became unable to care for yourself at home, where would be your preferred place of care? (E.g. s taying at home with visiting carers, s taying with friends, s taying at a hospice)
Firs t choice:
Second choice:
When considering the end of your life, where would you prefer to be?
At home with visiting carers and specialis ts
Staying at Royal Trinity Hospice
In hospital
In a/your care home
Somewhere else (please state)
Should you become seriously ill or injured, what would be your preference around life support / life sus taining treatment?
(If you have previously signed an ‘Advance Decision to Refuse Treatment ’ (ADRT) document , please check your recorded wishes correspond with what you write here)
I would be willing to be kept on life support
I would not want to be kept alive in this way
Is there anything that you wish to tell your care team in order for them to meet your cultural or religious practices or requirements, e.g. reques ting a female chaperone, space to pray, meal preferences?
Organ donation
Organ donation may be something you have considered. We can provide you with information about corneal and tissue donation , both of which can make a real difference to people who require transplants or treatment for an illness.
Mos t people with a terminal illness are not able to donate their organs after death. However, mos t are able to give their corneas and often other tissues. More information on this can be found at: www.royaltrinityhospice.london/tissue-donation
Yes, I am interes ted in corneal and/or tissue donation
No, I am not interes ted in donating
Your life
Are you in employment? Yes No (please select)
If you answered yes,
Name of employer:
Website link:
Contact details:
OR
Name and details of your business:
Do you have any dependants who rely on you or who you care for?
Yes No (please select)
If you answered yes,
Person one: Name:
Address:
Age:
Person two: Name:
Address:
Contact number:
Pos tcode:
Age:
Contact number:
Pos tcode:
What do the people caring for you need to know about any cultural considerations? Are there any spiritual rituals that you would like observed in the lead up to, during and after your death?
Who, if anyone, would you like to advise on spiritual , cultural and faith-based practices that are important to you?
Do you have any pets?
Please provide any information about them such as their name, breed, birth date, sex, whether they have a microchip, diet , any known medical issues and the vet they are regis tered with.
What is your pet ’s insurance provider and policy number?
Insurer ’s name: Policy number:
Who would you like to care for your pet(s) if you were no longer able to, or after your death?
Home contacts – do you have a cleaner, gardener, IT support person or driver?
Contact Type: (e.g. cleaner)
Name:
Contact Type: (e.g. cleaner)
Name:
Contact Type: (e g. cleaner)
Name:
Contact Type: (e.g. cleaner)
Name:
Contact number:
Contact number:
Contact number:
Contact number:
Can you provide details of any clubs, associations, unions, or religious bodies you are a member of and may pay into regularly such as membership fees?
Planning your funeral
Would you like to have a funeral service or would you rather not have any formal ceremony/service after you die?
Yes, I would like a funeral service
No, I would not like a formal ceremony / service
I would like an alternative way of me and my life being remembered
If you have already made arrangements for your funeral , please provide details of your chosen provider, any payment plan or preferred funeral director. You may also wish to lis t details of any allocation from your es tate.
If you have not made plans for your funeral but have a preferred funeral provider please lis t as much detail as you can below.
Please cite the name you would like to be referred to at your funeral / memorial service and any pronouns.
Details of burial or cremation
Do you have a plot arranged? Yes No (please select)
If yes, please provide details of location.
If not , where would you like to be buried?
If your preference is to be cremated, how would you like your ashes to be taken care of?
When you are buried or cremated, is your personal preference for your body to be in a:
Traditional wooden coffin/casket
Fabric shroud
Coffin made from natural materials
Biodegradable coffin e g. cardboard
Something else (please state)
Where do you wish for your body to res t before your funeral?
Do you wish to have your body embalmed? Yes No (please select)
Are there any clothes you would like to be dressed in for your funeral?
What elements of a funeral are important to you?
Traditional faith-based funeral in a location of religious importance to you (please specify where and which religion , belief, philosophy)
Humanis t ceremony
Life celebration
Direct cremation - attended
Direct cremation - unattended
Eco friendly
Is there a route special to you that you would like to be followed on the way to the crematorium / cemetery / burial site?
For the funeral service
Do you have a preferred person to lead your funeral?
If so, provide their name and contact information.
Name:
Contact number:
Is there anyone else you would like to nominate to help take part in the funeral? For example, as a coffin bearer, or to give a reading or performance.
Is there any music that you would like played or songs you would like sung?
Are there any readings, poems, words of wisdom or perhaps a letter from yourself that you would like included?
Are there any specific prayers or blessings?
Would you like flowers at your funeral? If so, what type?
Would you like a collection for a nominated charity or social club? Mos t charities can support with organising funeral collections, including providing donation envelopes.
If there is a certain dress code or other specifics you would like to be observed by those attending your funeral , what would they be?
Is there anyone you would not like to take part in your funeral?
Would you like your death announced publicly and if so, in what publication?
Is there a place you would like your family and friends to gather after your funeral?
Would you like a memorial or grave s tone?
Would you like a memorial tree, bench , or charitable collection?
Any there any extra details about your funeral you would like made known?