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Who would speak for you if you could not speak for yourself?
Write their name, and do these questions with them beside you if you can.
What matters most to you?
Circle as many as are true.
- Being at home
- Knowing what’s happening
- Not being in pain
- Having my family near
- My faith
- Still being myself
- Being able to look after myself
- Doing my part for the people I love
Anything else, in your own words:
Talk about it: Take turns. Tell each other about a time when one of these was true.
What does a good day look like?
Circle as many as are true.
- Time outside
- A quiet morning
- Family around the table
- Music
- My own things around me
- A visit from a friend
Anything else, in your own words:
Talk about it: Describe your best ordinary day out loud. What is the first thing that happens?
What still brings you joy?
Circle as many as are true.
- Grandchildren or young people
- Animals
- Good food
- Being useful
- Laughing
- Nature
Anything else, in your own words:
Talk about it: Say one small thing that would make an ordinary hard day better.
What would you not want?
Circle as many as are true.
- A breathing machine for a long time
- A feeding tube for a long time
- To die in an ICU if it can be avoided
- To be kept alive if I can’t know the people I love
- To be alone at the end
- Treatment that only draws out dying
- To live with pain that can’t be controlled
- To hold on mainly for other people’s sake
Anything else, in your own words:
Talk about it: Pick the one that matters most. Tell each other why, and what you’re afraid of.
If you were very sick and not expected to get better, what would matter more?
Circle one.
- Try every treatment available
- Focus on comfort, not on living longer
- It depends on the situation
- I’m still working through this
If your heart stopped, would you want CPR?
CPR is pressing on the chest and using shocks to restart the heart.
Circle one.
- Yes, try to restart my heart
- No, let it stop
- Only if there’s a real chance
- I haven’t decided
What would you want?
Circle as many as are true.
- Pain treated fully, even if I’m sleepier
- Honest information about what’s happening
- If I ask, a rough sense of my time, and more detail when it’s close
- To be at home, if it’s possible
- The people I love nearby
- Music, prayer, or quiet, my choice
- Time to say goodbye
- To choose who is with me at the very end
Anything else, in your own words:
Talk about it: Which one would be hardest for the people around you to give? Say so.
If things go differently than you expected, how much room should they have to decide?
Circle one.
- Follow my words exactly
- Use it as a guide, then decide
- I trust them to decide
Talk about it: Say this to each other in your own words: “Here is what I need you to do, and what I’m letting you decide.”
Where would you want to be?
Circle one.
- At home, if it’s possible
- In a hospice or care home near family
- Wherever the care is best
- I haven’t decided
Talk about it: Picture the room. Who is in it? What can you hear?
What calms you when you are frightened or in pain?
Circle as many as are true.
- Music
- Someone holding my hand
- Prayer or quiet
- Being told what’s happening
- Familiar voices
- Fresh air or a window
Anything else, in your own words:
Talk about it: Tell each other what you do when you can’t sleep or you’re scared.
If you could not respond, how should people treat you?
Circle as many as are true.
- Talk to me even if I can’t answer
- Keep me clean and covered
- Keep the room calm
- Call me by my name
- Play my music or read to me
Anything else, in your own words:
Talk about it: Say what you’d most hate to see happen, and what you’d most want.
Is faith or a spiritual practice part of this?
Circle one.
- Faith is an important part
- Faith is not part of this
- Private, I’ll say it in person
Talk about it: Is there someone you would want called? Say their name.
What do you want the people you love to hear?
Circle as many as are true.
- Thank you.
- I love you.
- I forgive you.
- Please forgive me.
- I’m at peace with my choices.
- I’ve made my choices. Let’s talk about other things.
Anything else, in your own words:
Talk about it: Say them now, to the person beside you. It is much easier to say them today. If one is hard to say, record it on your own phone so they can hear it later.
When you are done, keep the paper where the person who would speak for you can find it, and give them a copy. This is a values document, not a legal form: to make it official, copy your answers onto your state's advance directive form and sign it the way your state requires (CaringInfo has the form for every state).