Advance Life Care Questionnaire

Watch the short video to see what's in the questionnaire.

It typically takes only 10 - 15 minutes to complete.

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YOUR PRIORITIES FOR CARE

1

The following things are important for me to have a reasonable quality of life.

Choose as many as you like (these answers are ordered randomly each visit)

Other:
2

The following things are important for me to have a minimum quality of life and still want to continue living.

Choose as many as you like (these answers are ordered randomly each visit)

Other:

IF YOU LOSE CAPACITY

The next questions refer only to situations where you cannot speak for yourself and others have to make decisions about your medical treatment.

Rate each situation as if it was to occur within the next 12 months.

3

I cannot hear anything.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
4

I cannot see anything.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
5

I cannot talk to my loved ones, but I can hear them and understand what they say.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
6

I have mild to moderate pain and medication isn't helping.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
7

I have severe pain and medication isn't helping.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
8

I can only sleep for a few hours every night and medication isn't helping.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
9

I have persistent nausea and medication isn't helping.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
10

I cannot eat or swallow anything except sips of water.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
11

I have lost all control of my bladder.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
12

I have lost all control of my bowels.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
13

I am dependent on other people for all or most of my activities of daily living.

Activities of daily living include eating, toileting, showering, dressing.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
14

I am breathless for most of the day and medication is not helping.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
15

No-one is coming to visit me.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
16

My condition is impacting the lives of my loved ones and they are distressed by it.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
17

I do not recognise my family or my whereabouts.

Life is not worth living Okay for 3-4 weeks only Life is still worth living
18

I need to be admitted to hospital for intravenous antibiotic therapy.

Life is not worth living Okay for 3-4 weeks only Life is still worth living

IN AN EMERGENCY

The next questions deal with the possibility that you suffer a catastrophic event like a stroke, a heart attack, a complication in an operation, a major accident or a deterioration in a major illness like widespread cancer.

These questions ask whether you want Cardiopulmonary Resuscitation (CPR) and/or Life Sustaining Medical Treatments in these situations.

19

If I suffer a catastrophic event like a stroke, a major accident, a complication in an operation, or a deterioration in a major illness such as widespread cancer causing me to stop breathing and have no pulse, then:

20

If I suffer a catastrophic event like a stroke, a major accident, a complication in an operation, or a deterioration in a major illness such as widespread cancer, and life sustaining medical treatment is available, then:

You will be able to choose which life sustaining treatments you agree to.

The life sustaining treatments I agree to are:

Choose as many as you like







At least one treatment must be selected
21

If I am in the same state of health with the same quality of life as I have now and I suffer a heart attack that causes me to stop breathing and have no pulse, then:



REFUSING TREATMENTS

22

'Futile' medical treatment is treatment that is no longer helping to cure your illness, but may prolong your life. Life sustaining treatments are aimed primarily at keeping you alive, with interventions such as dialysis, intubations, tube feeding. Palliative Care is aimed primarily at minimising your distress rather than curing your illness or keeping you alive. Palliative care does not mean no treatment, only that the focus of treatment is management of pain and symptoms rather than attempting to cure your illness.

If medical treatment for me is deemed futile and referral to a palliative care specialist or service is available, then:

23

If I have a terminal condition, I would prefer:

24

If I have a terminal condition, I would prefer to die:


25

Are there any cultural, religious or family End-of-Life beliefs, customs and traditions that are important to you and your loved ones?

26

Are there any other messages, comments, explanations or directions you would like to make about your medical care to inform those who might have to make a decision on your behalf? If so, write them here.

CONFIRMATION

If you are ready to complete your questionnaire, please complete all the following confirmation checkboxes.



We know life circumstances change. Therefore you will still be able to easily update, edit, or change your answers to this questionnaire at any time after pressing Finish.

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