How important to you are the following items? Rate each as: 4 (Very important) 3 2 1 0 (Not important)
Letting nature take its course
Preserving quality of life
Staying true to my spiritual beliefs/traditions
Living as long as possible, regardless of quality of life
Being comfortable, and as pain free as possible
Leaving good memories for my family and friends
Making a contribution to medical research or teaching
Being able to relate to family and friends
Being free of physical limitations
Being mentally alert and competent
Being able to leave money to family, friends, or charity
Dying in a short while rather than lingering
Avoiding expensive care
Consider the following questions and add your answers:
What will be important to you when you are dying (e.g. physical comfort, no pain, family members present, etc.)?
How do you feel about the use of life-sustaining measures in the face of terminal illness? Permanent coma? Irreversible chronic illness, such as Alzheimer’s disease?
Do you have strong feelings about particular medical procedures? Some procedures to think about include: mechanical breathing (respirator), cardiopulmonary resuscitation (CPR), artificial nutrition and hydration, hospital intensive care, pain relief medication, chemo or radiation therapy, and surgery.
What limitations to your physical and mental health would affect the health care decisions you would make?
Would you want to have financial matters taken into account when treatment decisions are made?
Would you want to be placed in a nursing home if your condition warranted?
Would you prefer Hospice care, with the goal of keeping you comfortable in your home during the final period of your life, as an alternative to hospitalization?
In general, do you wish to participate or share in making decisions about your health care and treatment? Would you always want to know the truth about your condition, treatment options, and the chance of success of treatments?