Advance Directive — Patient Wishes Record
What a patient wants when they can no longer say so — the document that turns their voice into a clinical instruction
What it is
A record of a patient’s stated wishes regarding life-sustaining treatment, CPR, and end-of-life care, completed while the patient has capacity. Includes the patient’s own statement, witness signatures, healthcare proxy designation, and the alert flag for clinical staff. An advance directive filed in the records but not visible to the treating team is equivalent to no directive at all — this form includes a mandatory alert flag for the front of the patient file.
ASF criterion
Evidence for: Hospital Standard 4, criterion 4.35 (Core) — Advance Directives Are Sought, Documented, and Actually Followed.
| ADVANCE DIRECTIVE — PATIENT WISHES RECORD · ASF-TOOL-CAP-05 | |
|---|---|
| Patient full name | |
| Date of birth / ID number | |
| Date of this directive | |
| Capacity confirmed by (clinician) | |
| Patient’s stated wishes (in their own words or clearly paraphrased with patient confirmation): | |
| |
|
| Specific instructions | |
| CPR if cardiac arrest | ☐ Attempt CPR ☐ Do Not Attempt CPR (DNACPR) |
| Mechanical ventilation | ☐ Accept ☐ Decline ☐ Time-limited trial |
| Artificial nutrition/hydration | ☐ Accept ☐ Decline ☐ Patient preference: |
| Healthcare proxy (person to consult if patient lacks capacity) | |
| Name | |
| Relationship / Contact | |
| Patient signature | |
| Witness 1 name & signature | |
| Witness 2 name & signature | |
| ⚠ ALERT FLAG: Place a copy of this directive at the front of the patient’s clinical record AND in the medication chart. Inform all treating staff at every handoff. | |
ASF-TOOL-CAP-05 · Toolkit 33 · france-asf.fr/tools · ASF original © Accréditation Sans Frontières · CC BY-NC-SA 4.0 · Legal requirements for advance directives vary by jurisdiction — confirm with national law · Keep this line on all adapted versions
