Step 1 of 6 16% Contact InfoYour Name First Last Email You will need to provide your e-mail address if you would like a PDF of your plan e-mailed to youStep 1: ThinkWhat makes my life meaningful?For example, spending time with family and friends, being able to practise my faith, being active, being able to do my hobbies.What do I value most about my mental and physical health? Being able to live independently Be able to recognize others Being able to communicate with others Having my privacy Being able to still do my hobbies Keeping my dignity Having family and friends nearby Other Choose any of these that are important to you – and add other comments if you wish.Share additional thoughtsWhat would make prolonging my life UNACCEPTABLE for me? Being in a coma with little or no possibility of waking up Not being able to communicate with others Being a burden to family members A loss of privacy Losing control of my bodily functions Being in pain Having to stay in bed but still able to communicate with others Being kept alive with machines with no chance of survival Other Choose any of these that are important to you – and add other comments if you wish.Share additional thoughtsIf I were ill, what would be important for others to know?When I think about dying, I worry about certain things happening: Being in pain Struggling to breathe Being alone Losing my dignity Other Choose any of these that are important to you – and add other comments if you wish.Share additional thoughts Step 1: Think (continued)When I think about the end of life, I worry about: Who can I talk to about these worries?If I were nearing death, what would I want to make things more peaceful for me? Family and friends nearby Be able to die at home Have spiritual support Having specific music played Having specific photos Other Choose any of these that are important to you – and add other comments if you wish.Share additional thoughtsIf possible, would I prefer to die at home, in a hospice or in the hospital? What might change my mind about my choice?Do I have any spiritual or religious beliefs that would affect my care at the end of life? If so, what are they?Other wishes and thoughtsWrite down anything that would help others understand and support you at the end of life. Step 2: LearnHow important is it that I be comfortable and suffer as little as possible? Not at all important Not very important Somewhat important Very important How important is it that I live as long as possible? Not at all important Not very important Somewhat important Very important How important is it that I avoid being attached to machines and tubes? Not at all important Not very important Somewhat important Very important How important is it that I respect the wishes of other family members regarding my care? Not at all important Not very important Somewhat important Very important How important is it that I am involved in making decisions about my care? Not at all important Not very important Somewhat important Very important Step 3: DecideMy Substitute Decision Maker Is: First Last Relationship Address Street Address Address Line 2 City Province AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Postal Code PhoneEmail Do you have more than one Substitute Decision Maker? Add their information here. Step 4: TalkWho do I want to talk to? Who else? Partner/Spouse Child/Children Mom Dad Caregiver Doctor Friend Spiritual leader Other Who else? When is a good time to talk to them? Think about when you might approach your loved ones – for example, at a family gathering, over a meal, before my next big trip, etc.)Where is a good place to talk? Think about where you might have the conversation – for example, at the kitchen table, at a restaurant, during a walk or drive, at the cottage, etc.)What do I want to be sure to say? List the most important things you want to make sure you’ll talk about during your conversations: Step 5: RecordOther wishes and thoughtsWrite down anything that would help others understand and support your future health care or end-of-life care.My other planning documents: Power of Attorney (financial) Will Organ Donation Other (e.g. funeral plans, bequests, etc.) In addition to this Advance Care Plan, I have also completed the following documents (check all that apply and note the location of each document):Location (Power of Attorney) Location (Will) Location (Organ Donation) Other (please explain) This is the final step in completing your Advance Care Plan. Once you click on "Complete My Plan" a PDF version will be available to you as well as emailed to you if you provided your email address. View our Privacy Policy. (This link will open in a new window for your convenience.)EmailThis field is for validation purposes and should be left unchanged. Make a PlanHow To Use This Workbook Step 1: Think Step 2: Learn Step 3: Decide Step 4: Talk Step 5: Record Complete Online Workbook (The instruction guides above will open new tabs in your browser to avoid losing your work.) (Les guides d’instruction ci-dessus ouvriront de nouveaux onglets dans votre navigateur afin d’éviter la perte de votre travail.)
