Before having your health care agent sign any forms, you should discuss your beliefs and wishes with him or her. When instructing your health care agent about your wishes in the event you become incapacitated and they need to make health care decisions, we suggest you consider the following questions. We suggest no particular answers. Each person should answer these questions based on their own beliefs and convey those beliefs and wishes to their health care agent. Any other wishes or desires that you feel your health care agent should know should also be given to them so that they can carry out their responsibilities as you would wish.

1. Do you think it is a good idea to sign a legal document that says what medical treatments you want and do not want when you are dying? (This is called a "living will").

2. Do you think you would want to have any of the following medical treatments performed on you?

a. Kidney dialysis (used if your kidneys stop working)
b. cardiopulmonary resuscitation, also called CPR (used if your heart stops beating)
c. respirator (used if you are unable to breathe on your own)
d. artificial nutrition (used if you are unable to eat food)
e. artificial hydration (used if you are unable to drink fluids)

3. Do you want to donate parts of your body to someone else at the time of your death? (This is called "organ donation.")

4. How would you describe your current health status? If you currently have any medical problems, how would you describe them?

5. If you have current medical problems, in what ways, if any, do they affect your ability to function?

6. How do you feel about your current health status?

7. If you have a doctor, do you like him or her? Why?

8. Do you think your doctor should make the final decision about any medical treatments you might need?

9. How important is independence and self-sufficiency in your life?

10. If your physical and mental abilities were decreased, how would that affect your attitude toward independence and self-sufficiency?

11. Do you wish to make any general comments about the value of independence and control in your life?

12. Do you expect that your friends, family and/or others will support your decisions regarding medical treatment you may need now or in the future?

13. What will be important to you when you are dying (e.g., physical comfort, no pain, family members present, etc.)?

14. Where would you prefer to die?

15. What is your attitude toward death?

16. How do you feel about the use of life-sustaining measures in the face of terminal illness?

17. How do you feel about the use of life-sustaining measures in the face of permanent coma?

18. How do you feel about the use of life-sustaining measures in the face of irreversible chronic illness (e.g., Alzheimer's disease)?

19. Do you wish to make any general comments about your attitude toward illness, dying, and death?

20. What is your religious background?

21. How do your religious beliefs affect your attitude toward serious or terminal illness?

22. Does your attitude toward death find support in your religion?

23. How does your faith community, church or synagogue view the role of prayer or religious sacraments in an illness?

24. Do you wish to make any general comments about your religious background and beliefs?

25. What else do you feel is important for your agent to know?

If, over time, your beliefs or attitudes in any area change, you should inform your health care agent. It is also wise to inform your health care agent of the status of your health when there are changes such as new diagnoses. In the event you are informed of a terminal illness, this, as well as the ramifications of it, should be discussed with him or her. How well your health care agent performs depends on how well you have prepared them.

Listed below are suggested topics for you to discuss with your health care agent. This list is divided into various categories which should be considered. It is essential that you discuss your choices with your health care agent (and health care providers) while you are competent so that they fully understand what you want them to do.

Do you wish to require a physician's determination that the medical condition is irreversible coma, vegetative state, terminal condition, etc.?

Your Wishes On The Removal Of Life-Sustaining Procedures

1. I do not wish to be kept alive on life-sustaining procedures. My health care agent may determine the timing of the discontinuation of treatment.

2. My health care agent may make any decisions needed about life support procedures, including the decision to discontinue tube feeding and hydration and other treatments.

3. I do not wish to be kept alive on artificial life-sustaining equipment, including feeding or hydration, if these procedures would only serve to prolong the dying process or maintain me in a persistent vegetative state.

4. Do not start or continue life-sustaining procedures if my condition is stable and full independent functional capacity is not expected to return.

5. I do not want my life to be artificially or forcibly prolonged, unless there is some hope that both my physical and mental health may be restored.

6. I wish all tube feeding and hydration removed except the kind and amount needed to prevent stressful dehydration of the mouth and skin, so as to maximize comfort and minimize nursing care.

Your Wishes On The Continued Use Of Life-Sustaining Equipment

1. I wish that all life-sustaining equipment and tube feeding and hydration be used for as long as possible.

2. I wish that any medical treatment that will prolong my life be used, including chemotherapy, radiation treatment, kidney dialysis and tube feeding and hydration.

Your Wishes On Time Constraints

1. If I should be in a coma for at least _____ days and the coma is certified to be irreversible by a physician, I direct that all life-sustaining equipment, including tube feeding and hydration, be removed.

Your Wishes On Resuscitation And Other Heroic Measures

1. Do not start or continue life-sustaining procedures if my condition is stable and full independent functional capacity is not expected to return.

2. If death is imminent, I want respiration discontinued and no CPR.

Your Wishes On Organ Donation

1. My agent may not donate any organs under any circumstances.

2. My agent may authorize organ donations and autopsy.

3. I wish to donate my entire body to medical research.

Your Wishes On Nursing Home Placement

1. I would prefer not to be placed in a nursing home (and/or community-based residential facility) unless it is absolutely necessary and all community resources have been exhausted.

2. I prefer to stay in my own home as long as possible.

3. I prefer to go to a nursing home rather than impose on my children.

Your Wishes On Preferred Physician And/Or Long-Term Care Facilities

1. If consistent with my medical treatment, I would prefer to be treated at _________________________________ Hospital.

2. I prefer to be treated by Physician _________________________________, if possible.

3. If it is necessary for me to be placed in a nursing home, I would prefer (or prefer to avoid) _________________________________ Nursing Home.

Your Wishes On Revocation Of Prior Living Wills

1. I revoke any prior executed living will executed on ______________________ (date if possible). My health care agent can make the decision to withhold or withdraw life- sustaining procedures.

2. I authorize my health care agent to make all decisions not already covered in my living will so as to cover those conditions where I am not terminally ill and/or my death is not imminent, as well as all procedures not covered by my living will.

Your Wishes On The Use Of Experimental Treatment/Possible Suggestions For Patients Who Are HIV Positive

1. I wish my health care agent to authorize all experimental drugs and treatment available which are supervised by a licensed health care professional.

2. I wish no AZT or other experimental drugs or experimental procedures if these procedures would only serve to prolong the dying process or maintain me in a vegetative state.

3. I authorize my health care agent to disclose my condition and prognosis only to my health care providers and X, Y and Z.

4. I wish my health care agent to authorize all comfort measures, including narcotics, to the extent necessary to alleviate all of my pain, regardless of the possibility of addiction.

Your Wishes On The Alleviation Of Pain

1. My desire is that pain should be alleviated to the extent possible, even though its use may lead to physical damage, addiction or even hasten (but not cause) death.

Your Wishes On Religious Preferences

1. I wish to be treated at a (Catholic, Lutheran, etc.) nursing home/hospital if at all possible.

2. I wish to have religious services provided to me once a week, even if I am unable to fully participate.

3. In the event of a terminal or life threatening situation, I wish to receive my last rites.

4. I wish to be visited by my minister/priest/pastor on a regular basis.

Your Wishes On Visitation

1. I wish that only X, Y and Z be allowed to visit me.

2. I want all visitors to be able to visit me, unless inconsistent with my medical treatment.

Your Wishes Regarding Consultation

1. I would like my health care agent to consult with _________________________________ before making any of my health care decisions.

2. I wish my health care agent to keep my children informed of my health care condition.

Any Miscellaneous Wishes

1. If at all possible, I wish to be able to listen to _________________________________ music at least once a day/week.

2. I do not want to wear checks/plaids/purple/polyester when I am no longer able to choose my own clothing.

3. If at all possible, I want the daily/Sunday paper/books delivered to me regardless of my ability to comprehend their contents.

4. Unless it would be inconsistent with my health care, I never want to be put on a diet simply to control my weight.