Try: As a healthcare agent or representative for the Care recipient (cr) you may have to make decisions based on what the cr would prefer if he or she were capable of making that decision if possible use this form to discuss the cr cr’s preferences beforehand you may use this form in the following two ways list your preferences if you were in the same situation and then discuss those preferences with the cr or simply go through the form with the cr and record his or her responses and preferences health care agent or representative – discussion and preparation form 1 circle how much you fear the following near the end of life a being in pain very little some very much b losing the ability to think very little some very much c being a financial burden on loved ones very little some very much d losing control over my medical care very little some very much e losing ability to practice my faith very little some very much 2 is it more important for you to a have your wishes followed at the end of life even if family members or friends disagree or b have family and friends all agree on decisions even if different from how you would decide or c i am uncertain 3 here are things about end-of-life care that some people believe do you agree if a dying person can’t get enough nutrition by mouth a feeding tube should always be used if it will keep the person alive a yes i agree b no i don’t agree c i don’t know once a treatment is started to keep someone alive it’s sometimes okay to decide to stop and withdraw it when the person’s quality of life is very low a yes i agree b no i don’t agree c i don’t know it’s usually better for a dying person to be given good comfort care at home than to be admitted to a hospital for intensive care a yes i agree b no i don’t agree c i don’t know 4 you are very sick and the health care professionals cannot stop the disease with all possible treatments you might live for another few weeks during that time you would be on a breathing machine you would drift in and out of consciousness without these treatments you would die in a few days would you want the breathing machine and other treatments a yes i think so b no probably now c i don’t know 5 you have severe alzheimer’s disease you can’t get out of bed and you can’t recognize or talk with your loved ones but you are not in pain you could live like this for many months however you get recurring infections which are treated with antibiotics you get another infection this time pneumonia if the health care professionals give you an antibiotic you will almost certainly recover from the infection without the antibiotic you will die in a few days do you want the antibiotic if you can otherwise be kept comfortable a yes i think so b no probably not c i don’t know 6 you have poor circulation which resulted in one leg being amputated now your other leg develops gangrene and health care professionals recommend amputation because it could be fatal you also have moderate dementia causing mental confusion would you want the operation a yes b no c i am uncertain 7 you are in a permanent coma and have a tube inserted in your stomach for food and fluids what would you want a remove tube b keep tube c i am uncertain 8 describe what other treatment you would want check all that apply and or list any treatment that you do not see listed a antibiotics b artificial respiration c cpr d other list 9 would it be important to you that decisions about your treatment are guided by particular religious beliefs or spiritual values that you hold a yes b no c i am uncertain 10 you are terminally ill but a course of treatment might extend your life by six additional months would you want the treatment even though it has severe side effects – pain nausea vomiting and weakness a yes b no c i am uncertain 11 do you wish to donate any organs and or tissues for transplant or research a research b transplant c both d neither 12 if you chose either answer "a " "b" or "c" in question 11 please list the organ s and or tissues that you wish to donate below 13 if you have any additional wishes or preferences in regard to medical treatment or the withholding of treatment please list below disclaimer this is not an advance directive these questions and form are for discussion purposes only information references adapted from making medical decisions for someone else a new hampshire handbook 2007
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Categories: Caregiver Needs&Support, Cognitive Intellectual, Communication, Emotional Psychological, Spiritual
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Keywords: End of life care nutrition artificial respiration cpr
*This information is listed as a Fact Sheet and is not explicitly medically licensed