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The following summarizes an advanced care planning conversation that happened on [date name="Date"]. This was a voluntary conversation.

The following individuals were present for today's conversation:
[checkbox name="Individuals_Present" value="Patient|Patient's designated healthcare power of attorney|Patient's family members|Patient's caregiver"][textarea name="Names" memo="Insert person's names here or leave blank"]

What is your understanding now of where you are with your illness?
[select name="Understanding" value="No understanding of prognosis|Overestimate prognosis|Appropriate understanding of prognosis|Underestimate prognosis"]

How much information about what is likely to be ahead with your illness would you like from me?
[select name="Information" value="Patient/POA wants to be fully informed|Patient/POA wants to be informed of big picture, but no details|Patient/POA wants some information, but no bad news|Patient/POA does not want any information for him/herself"]

What did you (MD/NP) communicate to the patient?
[select name="Prognosis" value="More than a year|Several months to year|Several weeks to month|Days to weeks|Did not discuss"]
[textarea name="Why" memo="Reason prognosis not discussed or leave blank."]

What are your most important goals if your health situation worsens? For example, being at home, being mentally aware, being in control of decisions, not being a burden, achieving a life goal, supporting my children.
[checkbox name="Goals" value="Live as long as possible, no matter what|Be physically comfortable|Not be a burden|Have my medical decisions respected|Be spiritually and emotionally at peace|Be at home|Be mentally aware|Be independent|Provide support for family|Achieve particular life goal"]
[textarea name="Specific_goals" memo="List specific goals here or leave blank."]

What are your biggest fears and worries about the future with your health?
[checkbox name="Worries" value="Pain|Concerns about meaning of life|Loss of control|Finances|Spiritual distress|Other family concerns|Preparing for death|Emotional distress|Ability to care for others: children, spouse|Loss of dignity|Other symptoms|Burdening others|Getting treatments I do not want|Other"]
[textarea name="Other_worries" memo="List other worries here or leave blank."]

What gives you strength as you think about the future with your illness?
[checkbox name="Strength" value="Faith|Family"]
[textarea name="Other_strengths" memo="List other strengths here or leave blank."]

What abilities are so critical to your life that you can’t imagine living without them?
[checkbox name="Abilities" value="Being conscious|Not being in pain or being very comfortable|Being able to care for myself, including toileting and feeding|Being able to talk|Being myself|Being able to interact with others"]
[textarea name="Other_abilities" memo="List other abilities here or leave blank."]

If you become sicker, how much are you willing to go through for the possibility of gaining more time?
[checkbox name="Additional_interventions" value="Be on a ventilator|Be uncomfortable|Be in the ICU|Have a feeding tube|Live in a nursing home|Be in the hospital|Undergo aggressive tests and/or procedures"]

How much does your family know about your priorities and wishes?
[select name="Family_knowledge" value="Extensive discussions with family about goals and wishes|Some discussions, but incomplete|No discussion but plans to address these issues|No discussion, wants help in talking to family|Wants clinician to talk with family|Does not want family informed"]

[select name="Advanced_directive" value="The patient has completed the Ohio Advanced Directive. No changes were made today.|The patient has completed the Ohio Advanced Directive. Changes were made today.|The patient has not completed the Ohio Advanced Directive. Paperwork provided.|The patient does not want to complete the Ohio Advanced Directive."]

Advanced directive details:
The patient's designated healthcare power of attorney is:
[text name="HCPOA" default="Not established, paperwork provided"]

The most appropriate code status for the patient at this time if the patient is in cardiac arrest (patient has no pulse and is not breathing):
[select name="Code_status" value="Attempt rescucitation/CPR with full treatment and intervention|Do NOT attempt rescuscitation/DNR. No CPR."]

If the patient has a pulse and/or is breathing, offer:
[select name="Medical_Interventions" value="Full intervention, including intubation, mechanical ventilation, and cardioversion. Transfer to intensive care if indicated.|Limited additional interventions, including medical treatments, IV fluids, and cardiac monitoring. do not use intubation or mechanical ventilation. May consider airway support such as CPAP or BiPap. Transfer to hospital if indicated. Avoid intensive care.|Comfort measures only. Use medication by any route, positioning, wound care, and other measures to relieve pain and suffering. Use oxygen, oral suction, and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital, unless comfort needs cannot be met in current location."]
[textarea name="Other_notes" default=""]

Antibiotics:
[select name="Antibiotics" value="Use antibiotics if clinically indicated|Determine use or limitation of antibiotics when infection occurs|No antibiotics. Use other measures to relieve symptoms of infection"]

Artificially Administered Hydration/Nutrition:
(Always offer food and liquids by mouth if feasible)
[select name="Nutrition" value="Long-term hydration/nutrition by tube|Trial period of hydration/nutrition by tube|No hydration/nutrition by tube"]
The following summarizes an advanced care planning conversation that happened on . This was a voluntary conversation.

The following individuals were present for today's conversation:
Insert person's names here or leave blank

What is your understanding now of where you are with your illness?


How much information about what is likely to be ahead with your illness would you like from me?


What did you (MD/NP) communicate to the patient?

Reason prognosis not discussed or leave blank.

What are your most important goals if your health situation worsens? For example, being at home, being mentally aware, being in control of decisions, not being a burden, achieving a life goal, supporting my children.

List specific goals here or leave blank.

What are your biggest fears and worries about the future with your health?

List other worries here or leave blank.

What gives you strength as you think about the future with your illness?

List other strengths here or leave blank.

What abilities are so critical to your life that you can’t imagine living without them?

List other abilities here or leave blank.

If you become sicker, how much are you willing to go through for the possibility of gaining more time?


How much does your family know about your priorities and wishes?




Advanced directive details:
The patient's designated healthcare power of attorney is:


The most appropriate code status for the patient at this time if the patient is in cardiac arrest (patient has no pulse and is not breathing):


If the patient has a pulse and/or is breathing, offer:



Antibiotics:


Artificially Administered Hydration/Nutrition:
(Always offer food and liquids by mouth if feasible)

Result - Copy and paste this output:

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