Dear Dr. _______________________________ :
It is important to me to have excellent and compassionate care - to stay as healthy and active as possible over the course of my life. At the end of life, my personal values and beliefs lead me to want treatment to alleviate suffering. Most importantly, I want to ensure that if death becomes inevitable and imminent, the experience can be peaceful for me and my family.
If there are measures available that may extend my life, I would like to know their chance of success, and their impact on the quality of my life. If I choose not to take those measures, I ask for your continued support.
If my medical condition becomes incurable, and death the only predictable outcome, I would prefer not to suffer, but rather to die in a humane and dignified manner.
I would like your reassurance that:
- If I am able to speak for myself, my wishes will be honored. If not, the requests from my health care representative and advance directives will be honored.
- You will make a referral to hospice as soon as I am eligible, should I request it.
- You will support me with all options for a gentle death, including providing medications that I can self-administer to help my death be as peaceful as possible.
I am not requesting that you do anything unethical while I am in your care, but I hope for your reassurance that you would support my personal end-of-life care choices as listed above. I hope you will accept this statement as a fully considered decision, and an expression of my deeply-held views. If you feel you would not be able to honor such requests, please let me know now, while I am able to make choices about my care based on that knowledge.
Print Name: ______________________________