Cheshire and Wirral Partnership Trust’s Advance Statement. “What I would like to happen if I become unwell.” Start your own today!

Cheshire and Wirral Partnership Trust’s

Advance Statement.

 

 “If at any time I experience a mental health crisis, I would like 

the following statement to guide my care and treatment.”  

 

An Advance Statement is a document for mental health service users to create when they are well to set out their treatment preferences and wishes should they become unwell in the future.

These wishes, based on previous experiences, can be helpful to professionals and carers, particularly at a time when a service user is experiencing a mental health crisis and may not be able to explain.

Making an Advance Statement helps people to make contingency plans about their home life and family and this can reduce anxiety and mental distress at the point of admission.

 

Objectives of Advance Statements.

  • —To enable service users to feel empowered to explain their mental health and how it affects them and their families and carers.
  • — To enable service users and carers to become actively involved in the planning and decision making regarding their care and treatment.
  • —To enable service users to be proactive in their recovery process and work in partnership with services and carers.
  • —To reduce anxiety and stress about becoming unwell.
  • —To help service users, carers and professionals to work together more effectively.

 

What is an advance statement?

 

An advance statement is a statement made when you are well of how you would wish to be treated if you were to suffer a further episode of mental illness.

 

What happens once I have completed an advance statement?

 

When you have completed an advance statement your doctor / care co-ordinator or any other mental health professional involved in your care will be obliged to take what you have written seriously and use it as a guide to your care and treatment. We will also make sure that, if you give us a copy of your statement, it is kept confidentially and is accessible to the professionals involved in your care.

Your statement works best if discussed with everyone you mention in the document.

 

Who can make an advance statement?

 

Anyone at any time can make an advance statement as long as they are well. It can be completed on your own, or your care co-ordinator, doctor, relative, friend or advocate can give you help and advice.

 

Advanced statements are made up 6 parts

 

Part 1 ABOUT ME: Your symptoms, history and things, including medication, that have worked well for you in the past. It is also an opportunity to tell us about what you are like when you are well.

 

Part 2 IF I BECOME UNWELL: What you would like to happen if you become unwell, what may trigger you, signs to look out for when you are becoming unwell and things thaty can make the situation worse

 

Part 3 ABOUT THE PEOPLE I WOULD LIKE TO BE INFORMED AND INVOLVED: Tells us about who you would like to be told about your treatment, involved in discussions about your treatment and any changes in your treatment plan.

 

Part 4 IF I AM ADMITTED TO HOSPITAL: An opportunity to tell us about your special needs and anything that would make your stay in hospital more comfortable and facilitate your recovery.

 

Part 5 WHEN I AM DISCHARGED FROM HOSPITAL: What you want to happen when you go home and who you want to support you in your recovery

 

Part 6 WHAT TO DO, WHO AND HOW TO CONTACT IN A CRISIS: Outlining your crisis plan and the actions to be taken by you and your care team. This section includes contact numbers as an easy reference in a crisis. 

 

 

Guidance for completing an advance statement

 

  • Not all sections need to be completed – just those you wish to complete
  • An advance statement is very important and personal to you
  • You cannot insist on receiving certain treatments but you can express your opinion about treatment, which may be based on what has / hasn’t worked previously. This provides you with an opportunity to say which treatments you don’t want.
  • The Mental Health Act overrides an advance statement. However, your doctor and treatment team should try to follow your wishes as much as possible and they should be able to explain to you why they are deviating from your advance statement.
  • If you change your mind about any of the contents of your advance statement, it can be updated at any time.

 

Who should I give my advance statement to?

When you have completed your advance statement it would be advisable to give a copy to:

  • Friends / supporters or relatives or any other person mentioned in your advance statement
  • Your care co-ordinator or other mental health care worker involved in your care [This is to ensure that should you become unwell those providing your care are aware of your wishes]
  • Your GP
  • You should also keep a copy for yourself.

ADVANCE STATEMENT

 

This is the advance statement of:

 

Name……………………………………………………………………………

 

Address…………………………………………………………………………

 

…………………….…………………….…………………….……………………

 

Date of birth……………………………………….………………………….               

 

Date……………………………………………………….………………………

 

 

PART 1: ABOUT ME:

 

What I am like when I am feeling well

(e.g. my personality, my lifestyle, my relationships etc.)

 

 

 

 

History and symptoms of my illness.

 

 

 

 

Things that trigger me to become unwell.

 

 

 

 

Early warning signs that I am becoming unwell.

 

 

 

 

When I am not well these are the things you will notice about the way I am (e.g. changes in my personality, lifestyle, relationships etc.)

 

 

 

 

Things that escalate the situation when I’m unwell.

 

 

 

 

PART 2:   IF I BECOME UNWELL:

 

If I am not well I would like the following to happen if possible (eg stay at home with the home treatment team visiting, stay with my mother, admission to hospital)

 

 

 

 

 

Why would I prefer this:

 

 

 

 

Things that have worked well for me in the past:

e.g. specific medication, talking therapies

 

 

 

 

 

Things that have not worked well for me in the past:

e.g. specific medication

 

 

 

 

 

Known allergies to medication [please list]

 

 

 

 

PART 3: ABOUT THE PEOPLE I WOULD LIKE TO BE INFORMED AND INVOLVED

 

I would like my carer/relative [name]………………………….to be involved and listened to when an assessment is made in a crisis.       Yes/No

 

I would like mental health services to immediately tell the following people if I am admitted to hospital. 

Name

Their connection to me

Contact details

Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:

 

 

When I am in hospital I would like the staff to talk and explain to my carer/relative [name]……………………………………. ….about my treatment.         Yes/No

 

Further details:

 

 

 

I would like my carer/relative [name]…………………………… to be notified of any changes in my medication/treatment plan. Yes/No

When I leave hospital I would like my carer/relative [name]………………………… to be informed what to do in case of a relapse. Yes/No

 

If I get any home leave from hospital I would like the following person[s] to be informed.

 

Name

Their connection to me

Contact details

Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:

 

 

I would like the following person[s] to assist me and represent my wishes at meetings that take place about my care e.g. ward rounds, Multi-Disciplinary Team meetings, tribunals.

 

Name

Their connection to me

Contact details

Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:

 

Other people to contact to tell them that I am not at home at the moment  e.g.. work, voluntary work, delivery people etc.

 

Name

Their connection to me

Contact details

Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:

Anything you want us to know about your family and home situation eg: you have pets

 

 

 

 

Names and ages of dependent children in my care (if applicable)

Name

Age

 

 

Schools my children attend and contact names and telephone numbers of teachers [if applicable]

 

Name

School

Contact details

Tel:
Tel:
Tel:

I would like the following people to care for my children/dependants/pets [delete as necessary]

 

Name

What you need them to do

Who do you want them to care for?

Contact details

 

 

When someone is explaining to my children what is going on I would wish that they were told the following.

 

 

 

 

And be told by     ………………………………………………………………

 

Who will take care of my finances and home [key holder]?

 

Name

Their connection to me

Contact details

Tel:Email:
Tel:Email:
Tel:Email:
Tel:Email:

 

PART 4: IF I AM ADMITTED TO HOSPITAL

 

Interests and activities I do already eg: walking, gym, reading, cooking

 

 

 

 

Things I like doing when in hospital that make me feel better and help me recover.

 

 

 

 

Pet hates and other things people should know about me: [eg: I hate people calling me ‘dear’, I am grumpy in the morning]

 

 

 

 

Things I want to have with me if I am admitted to hospital eg: photo of my children, my diary, my glasses

 

 

 

 

 

Any special needs (diet/religious and cultural needs/physical health/disabilities) and what I need because of this problem eg: information in written form, no sugar in diet

 

 

 

 

 

PART 5: WHEN I AM DISCHARGED FROM HOSPITAL

 

Who I would like to come home with me from hospital and help me sort my home out?

Name……………………………………………………………………………

 

Relationship to you…………………………………………………………

 

Contact details………………………………………………………………

 

Who I would like to go through my finances/bills/open stack of mail? Ensure services/phone working. Contact friends/work.

Name……………………………………………………………………………

 

Relationship to you………………………………………………………

 

Contact details………………………………………………………………

 

Who I would like to help me plan some activities?

 

Name……………………………………………………………………………

 

Relationship to you………………………………………………………

 

Contact details……………………………………………………………

 

Things I would like to do when I come home from hospital.

 

 

 

 

 

 PART 6: WHAT TO DO AND HOW TO CONTACT SERVICES IN A CRISIS

 

Action to be taken in the event of crisis:

 

By you

 

 

 

 

By your carer

 

 

 

 

By a Professional

 

 

 

 

Who to contact [Team and telephone number]

 

 

Who?

Contact details

Daytime

Evening

Weekend

 

  

I developed this plan on …………/……………/……………

 

With the help of: list who helped you to develop your plan – if there was anyone

……………………………………………………………………………………

……………………………………………………………………………………

……………………………………………………………………………………

 

Any plan with a more recent date on it replaces this one

 

Signed [your signature]…………………………………………

 

Date…………/……………/……………

 

Witnessed by [optional]:

 

Signature………………………………………………………………………

 

Name……………………………………………………………………………

 

Date…………/……………/…………… 

 

 

Copies of my advance statement should be sent to the following people:

 

Eg: Carer/relative/friend/GP/Care team [to be put on Carenotes]/Legal Advisor

 

Name

Their connection to me

Address

 

 

 

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