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Advance Care Planning Forms

Download official and easy-to-use advance care planning forms to record your future health care wishes and choose a trusted decision-maker.

In Case of Emergency (I.C.E) Form​

Includes personal identification information, emergency contacts, medical conditions and medications.

Temporary Substitute Decision Maker Form

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a TSDM is a person chosen by a healthcare provider to make medical decisions for an adult who is mentally incapable of giving informed consent includes a list of Substitute Decision Makers. This downloaid includes a list of possible TSDM's.

MOST

Medical Order of Scope of Treatment

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​Outlines your exact choices for life-support and emergency medical care if you become unable to speak for yourself

MOST -Info Pamphlet

MOST - Form

No Cardiopulmonary Resuscitation (DNR) Form

Allows patients to request no CPR administered should their heart or breathing stop.

Representation Agreement (RA9) 

For adults with full mental capability, granting comprehensive decisions over health, personal care and end-of-life decisions.​

Representative Agreement (RA7)

For adults whose full mental capability is in question or declining. It grants limited, routine decisions.  ​

Enduring Power of Attorney

Legal document that lets you appoint someone you trust (your 'attorney') to manage your financial and legal affairs if you become incapable or unable to do so yourself.  â€‹

Expected Death in The Home (EDITH) Form

A form used for individuals who are near the end of life and choose to pass away at home. When signed by a physician, this form instructs first responders and police not to attempt resuscitation.

Salt Spring Hospice Society
202- 118 Fulford Ganges Rd,

Salt Spring Island, BC, V8K 2S4

Hours of Operation:

Mon-Fri: 9am-3pm

Excluding Stat Holidays

office@saltspringhospice.org

250-537-2770​

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