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Advance Care Plan Example by JK

JK is a 58-year-old RN who worked most of her 35-year nursing career in critical care/intensive care Units. She is motivated to help people create their own advance care plans after experiencing the process of what families go through to make decisions regarding initiating, continuing, or stopping life support for loved ones who are too sick to speak for themselves. Countless times she has witnessed how making what may be life ending decisions for loved ones is difficult for many to do. “But if we have had the conversation and are carrying out the wishes that we have heard our loved ones say, then it is something we can do no matter how difficult the circumstances may be”. She is willing to share her personal advance care plan as a resource for others wishing to develop their own.

Printable Version

My Beliefs, Values, and Wishes

I believe that quality of life is far more important than length of life. For me "quality of life" includes thing such as:

  • staying active and enjoying walking, dancing, biking, swimming, and the great outdoors
  • spending time with my family and friends, and people in general
  • being able to give and receive hugs and kisses
  • being independent
  • feeling joy, enjoying humor, and laughing
  • enjoying the taste of good food and my favorite wine

When l think about what my death could be like, I take comfort in:

  • knowing any pain I have will be treated, even if that requires large amounts of medications
  • believing I won't be left struggling to breathe
  • believing I will have good care, including keeping me clean and my mouth fresh. (Please remember to brush my teeth at least once a day and moisten my mouth and lips often.)
  • believing my life will not be prolonged unnecessarily
  • believing my family will be with me if possible

When I think about dying I worry that:

  • I may struggle to breathe
  • I may have uncontrolled pain

When I am nearing the end of my life I want:

  • my family nearby if possible
  • to stay at home as long as l am not a burden on my family. It will be up to my family to decide when my care has become too much for them at home. At that point I would like to go to a hospice facility or a designated hospice unit. I hope that my family can make this decision free of guilt, knowing it is my wish.
  • if possible, a window with something nice outside to look at and hopefully one that will open and allow me some fresh air
  • someone holding my hand at times
  • to hear people talking gently about my life's happy memories
  • show me photos and talk about the adventures they represent
  • music at times, any type
  • quiet at times

My wishes for after my death:

  • I would like to be cremated and have my ashes sprinkled into the ocean in front of my favourite campsite at Denman Island.
  • I would like a little plaque in my honor on a small bench overlooking the beach there. If that is not allowed, the bench and plaque aren't necessary.
  • I would like my name added to my husband's plaque in Manitoba even though my ashes aren't there. That way I can be remembered with the rest of our family at that site.
  • I would like my family and friends to enjoy a celebration of life party in my honor.

My Wishes Regarding Health Care Treatment, Life Support, and Life-Prolonging Interventions

I am writing my wishes for my medical treatment to help my family and health care providers make decisions for me if I become too sick or confused to make medical decisions for myself. I believe that we have forgotten how to let people die in peace and with dignity and respect. If I become too sick or confused to have a good quality of life and the chances that I will return to a good quality of life are not good, I trust my family and health care providers to let me die peacefully.

I would like the opportunity to make my own decisions regarding continuing or stopping life support measures even if I can't tell you my name, the date, where I am, or answer questions appropriately every time. If I indicate in any way that I want to stop life support measures and have an endotracheal tube (ETT) taken out, then please do it. If I'm not clear mentally that's all the more reason I would not want to continue living.

No ETT and/or mechanical ventilator for more than 10 days. No tracheotomy for longer term mechanical ventilation. If I can't breathe adequately on my own within 10 days I would rather die than be ventilated on a long term basis. No wrist restraints to keep me from pulling out an ETT. Either keep me sedated enough to leave it alone, or take it out. If I am not heavily sedated because of the weaning process please have a person sit with me instead of using wrist restraints. If I insist on trying to get the ETT out, take it out. No weaning longer than 4 hours at a time.

No feeding tube for longer than 30 days. No permanent feeding tube. If I can't feed myself or look after toileting independently I don't want to live.

I'd rather be dead than to live without being able to get out of bed. If I reach a point where I have to be turned, fed, and bathed please let me die. This means no fluids, no nourishment, no medications except comfort medications, no antibiotics, no ETT, no ventilator, no CPR, no defibrillation, no pacemaker.

I'd rather be dead than be a quadriplegic. If I become a quadriplegic I would like to die comfortably and as quickly as possible. This means no fluids, no nourishment, no antibiotics, no heroics, no ETT, no ventilator, no CPR, no defibrillation, no pacemaker, no cardiac medicines or any medicines other than comfort medications.

Please keep me comfortable, even if it takes more than the usual amount of medication to do so. If I don't know my family members, put me in an extended care facility with strict "Do Not Resuscitate" orders. That includes no ETT, no ventilator, no CPR, no defibrillation, no pacemaker, no cardiac medications, and no feeding tubes. Please do not feed me if I cannot feed myself. Feel free to give me medications to keep me calm, happy, and comfortable. Do not take me to a hospital for treatment at that point unless it is necessary to relieve my pain. I do not believe in prolonging a poor quality of life or in making my family members have a poor quality of life to take care of me.

Once I become age 80, I do not want surgery for any reason unless it is necessary to relieve my pain or to improve my mental status. If that surgery is done, don't leave me ventilated post-operatively. If I can't wake up and breathe adequately postop please let me die. Once I become age 80 I do not want any heroics. I would demand "Do Not Resuscitate" status. No ETT, no ventilator, no CPR, no defibrillation, no pacemaker, no life-saving drugs.


Up until I am age 80, if something terrible happens to me, such as an accident or stroke for example, I would like my health care providers to try everything possible to save my life.

If I am in such a deep mental state that I cannot breathe on my own after 10 days of being on a ventilator please take me off the ventilator and remove my endotracheal tube. I realize this means I may die. I feel that the chance of returning to a reasonably good quality of life at this point is poor.

If I manage to breathe on my own but still cannot swallow, please continue my feeding tube for a total of 30 days.

If after 30 days I still cannot make my own medical decisions and I cannot feed myself or swallow please remove the feeding tube. At this point I would not want IV fluids for hydration either. I realize this means I will die.

Once I am age 80 I do not want a ventilator or any of the other heroic measures mentioned on the previous page. I do not want to lose the ability to have a sudden death.

I do not want to die in an intensive care unit.

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