Advance Care Directives

Advance Care Directives-Surveys for people who have done an ACD and substitute decision makers

We appreciate you taking the time to help us improve people's experiences with advance care directives. The first survey is for people who have completed an ACD, tried to complete one or helped someone complete one. The second survey is for people with experience of being a substitute decision maker.

You may complete one or both surveys.

Question Title

* 1. How easy or hard was it for you to get an ACD form?

Easy

Fairly easy

Neither easy nor hard

Fairly hard

Hard

Easy

Fairly easy

Neither easy nor hard

Fairly hard

Hard

Question Title

* 2. Where did you get your ACD DIY Kit or form?

I bought a DIY Kit or form from Service SA.

I downloaded a DIY Kit or form from the ACD website.

I completed my ACD online on the ACD website.

Other - Please tell us how you got your DIY Kit or form.

Question Title

* 3. How easy or hard was it for you to fill out the ACD form?

Easy

Fairly easy

Neither easy nor hard

Fairly hard

Hard

Easy

Fairly easy

Neither easy nor hard

Fairly hard

Hard

Question Title

* 4. If you used a DIY ACD Kit did you find it was:

Helpful.

Fairly helpful.

Neither helpful nor unhelpful.

Fairly unhelpful.

Unhelpful.

Helpful.

Fairly helpful.

Neither helpful nor unhelpful.

Fairly unhelpful.

Unhelpful.

Question Title

* 5. When you completed your ACD, did you appoint one or more Substitute Decision Makers?

Yes, I appointed one Substitute Decision Maker.

Yes, I appointed two Substitute Decision Makers.

Yes, I appointed three Substitute Decision Makers.

No, I did not appoint any Substitute Decision Makers.

Question Title

* 6. In Part 3 of the ACD form "What is important to me-my values and wishes" there are 6 areas the document suggests for you to consider when decisions are being made for you. Which of these things did you consider and include in your ACD?

When decision are being made for me, I want people to consider the following:

Outcomes of care I wish to avoid (what I don't want to happen to me):

Health care I prefer:

Where I wish to live:

Dying wishes:

Other personal arrangements:

Question Title

* 7. Part 4 of the ACD form allows you to fill our a section titled "Binding refusals of health care". In this part you can state what health care you do not want and the circumstances in which your refusal will apply. Did you fill out this section?

Yes.

No.

Question Title

* 8. Once you have completed your ACD it must be signed and witnessed. How easy or hard was it for you to find a witness?

Easy

Fairly easy

Neither easy nor hard

Fairly hard

Hard

Easy

Fairly easy

Neither easy nor hard

Fairly hard

Hard

Question Title

* 9. Did you complete your ACD yourself, or did you have a lawyer or someone else complete it?

I completed my ACD myself.

A lawyer completed my ACD

Someone else completed my ACD for me.

Question Title

* 10. Thank you for taking the time to provide us with this information. If there is anything further you would like to say about Advance Care Directives please use the textbox below.