The following inventory is designed to help you make decisions about the kind of healthcare treatment you may want and to help you share this information with your family, friends and healthcare providers.
Health Treatment
Please rate the following on a scale from 4 (very important) to 0 (not very important).
I want to let nature take its course without intervention
Quality of life is more important that quantity
Spiritual guidance must be part of my healthcare
I want to live as long as possible, regardless of the quality of my life
It is important to me to live independently
I want to be as comfortable and pain-free as possible
I do not want my family and friends to see me suffer
I want my experience to contribute to medical research/teaching
I want to be able to interact with family and friends
I do not want to live with physical limitations
It is important for me to be mentally alert and competent
I want to leave a positive legacy.
I do not want to experience a lingering death
I do not want to receive expensive care if I am not able to meaningfully interact with others.
What kind of support and care would you want if you were dying?
Please answer with “I want” or “I do not want”
Do you want life-sustaining measures in the face of a terminal illness? Are their certain illnesses or symptoms where you might choose not to have such measures and others where you would want life-sustaining measures? Please provide details.
Are there some specific treatments you would want or not want under any circumstances?
Are there some treatments you might want depending on your illness or injury?
Are there measures you would want only if you are not terminally ill?
Would you want to avoid treating ancillary issues if you are terminally ill even if it would potentially hasten your death?
What limitations to your physical and mental health would affect the healthcare decisions you would make?
Would the monetary cost of a particular treatment impact your decision?
Would you want to be placed in a nursing home if you needed ongoing medical care?
In general, do you wish to participate or share in making decisions about your healthcare?
Who else would you want to have participate in making decisions about your healthcare?
Would you always want to know the truth about your condition?
Would you want to be an organ donor at the time of your death?
If you were in an irreversible coma or a persistent vegetative state and, in the opinion of your doctor and at least two other doctors, had no known hope of regaining awareness and higher mental functions, then your wishes would be:
Cardiopulmonary Resuscitation: at the point of death, using drugs and electric shock to keep the heart beating
Mechanical Breathing: breathing by machine
Major Surgery: such as removing the gall bladder or part of the intestines
Kidney Dialysis: cleaning the blood by machine or by fluid passed through the belly
Chemotherapy: using drugs to fight cancer
Invasive Diagnostic Tests: such as using a flexible tube to look into the stomach
Blood or Blood Products: such as giving transfusions
Pain Medication: even if they dull consciousness and indirectly shorten my life
Antibiotics and simple diagnostic tests should be administered
If you were in a coma and in the opinion of your doctor and at least two other doctors, have a small possibility of recovering fully, a slightly greater possibility of living with permanent brain damage, and a much larger possibility of dying, then your wishes would be:
Cardiopulmonary Resuscitation: at the point of death, using drugs and electric shock to keep the heart beating
Mechanical Breathing: breathing by machine
Major Surgery: such as removing the gall bladder or part of the intestines
Kidney Dialysis: cleaning the blood by machine or by fluid passed through the belly
Chemotherapy: using drugs to fight cancer
Invasive Diagnostic Tests: such as using a flexible tube to look into the stomach
Blood or Blood Products: such as giving transfusions
Pain Medication: even if they dull consciousness and indirectly shorten my life
Antibiotics and simple diagnostic tests should be administered
If you have brain damage that is irreversible and significantly limits your ability to interact with people and you are terminally ill how do you feel about the following:
Cardiopulmonary Resuscitation: at the point of death, using drugs and electric shock to keep the heart beating
Mechanical Breathing: breathing by machine
Major Surgery: such as removing the gall bladder or part of the intestines
Kidney Dialysis: cleaning the blood by machine or by fluid passed through the belly
Chemotherapy: using drugs to fight cancer
Invasive Diagnostic Tests: such as using a flexible tube to look into the stomach
Blood or Blood Products: such as giving transfusions
Pain Medication: even if they dull consciousness and indirectly shorten my life
Antibiotics and simple diagnostic tests should be administered
Note: This document is not a legally-binding directive to physicians/health care directive. This is to be used to facilitate communication with my loved ones, and to guide my health care agent.