Prepare to Care Workbook | Page 11

ADVANCE CARE DIRECTIVES

Has the patient completed a Healthcare Power of Attorney?

• •

NO YES If YES, please include a copy of the document in this workbook

Has the patient completed a Living Will for a Natural Death, in addition to Healthcare Power of Attorney?

• •

NO YES If YES, please include a copy of the document in this workbook

Has the patient completed a Do Not Resuscitate order? NO

• YES •

If YES, please note location:

Has the patient completed an additional physician-ordered advance health directives( e. g., POLST,

• •

MOLST, POST, MOST)? NO YES If YES, please note location:

Other notes regarding advance directives:

FINANCIAL POWER OF ATTORNEY

Name:

Relationship to Patient:

Phone:

Note location of documentation:

> TIPS

• Always have the original copies of DNR orders and physician-ordered directives in a prominent location in the house.

• Make sure primary family members and providers have copies of healthcare advance directives and are aware of wishes.

CurePSP Prepare to Care 10