Most health care directive forms have a place where
you may write instructions or statements about your health care
preferences. This handout contains simple statements could be used
on any health care directive
The sample statements on this handout represent a
variety of values, beliefs and preferences. We offer these
statements not to support or promote any of them, but rather to help
you think about how to express your own values, beliefs and
preferences. Continuum Care, Inc. is available to assist you and
your loved ones complete your Health Care Directives at no cost.
General Statement about
Feelings, Values and
I have lived a good, long life. I am not
afraid to die. If I am near death, I do not want any treatments or
procedures that will only prolong my life rather than make it
Any decision about my care should be based on
the quality of the life it is likely to preserve. I would not want
my life extended if I could not understand what was going on around
me or recognize and interact with people I
I believe that every human being is valuable,
even if he or she is not aware of surroundings and cannot interact
with other people. So, even if I become mentally incapacitated, I
wish to be given the benefit of any treatment or care that will
extend or improve my life.
I believe that life is sacred and we should
do everything we can to preserve it. If a choice had to be made
between keeping me alive and keeping me comfortable, I believe that
I will always choose to be kept alive, even if it meant that I had
to endure pain.
Statements about Pain
Pain management and other additional Health Care
Because I watched my own father die in
excruciating pain, it is my wish that good pain control be the first
item of business in my care. I do not want to spend my last days (or
weeks, or hours) in pain. I would much prefer to be sedated and die
I believe that pain is a part of life. I
would rather experience pain than be so ďout-of-itĒ that I canít
interact with people I care about.
I believe that if God gives us pain, He has a
reason. I do not want to be drugged to the point that I donít feel
I hope that pain and other unpleasant
symptoms can be kept to a minimum. Iíd rather be awake and aware for
the last precious days of life, unless Iím in too much pain or
discomfort to enjoy them anyway.
Statements about specific treatment
Life would not be living if I had to be kept
on a respirator indefinitely.
I have no objections to temporary use of a
respirator or ventilator to keep me alive until I resume my own
If I am close to death, I do not want to be
put on a respirator or ventilator for any reason. If such treatment
has to be started, I wish to have it
Nutrition and Hydration
I understand that when a person is dying, the
body processes slow down and eventually cease. When this happens to
me and I can no longer take food or fluids by mouth, I do not want
foods or fluids by artificial means (tube or
I believe that food and water are not
medical treatments but basic necessities. I want food and water
provided by whatever means are necessary to keep
If death is imminent, I do not want
I want CPR under any
If I have an incurable terminal illness or
injury and my physician judges I will live only a week or less, even
if life saving treatment or care is provided to me, I do not want
Religious and Spiritual
Statements of religious or spiritual
I would prefer to be cared in a
If possible, I wish to be present for
religious services and have visits from my minister/priest/rabbi
even if I do not appear to understand or cannot fully
I want my family and friends to know that
because of my faith, I believe that Iíll be going to a better place
when I die. So if Iím near passing, I donít want them to try and
bring me back.
I do want anyone visiting me to pray for my
sins or to try and convert or save
General Statements about
Treatments to Support or Prolong
Feelings about Quality and Length of
start or continue life-sustaining procedures if my condition is
unlikely to improve and I am not expected to return to full
independent functional capacity.
Even if I
am likely to die within a few weeks or have an irreversible
condition that so debilitates me that I can no longer appreciate the
people and events in my daily life, I want any treatment that could
preserve my life or that could cure, improve, reduce or prevent
deterioration in my physical or mental condition.
Statements about Care
Your preferences about
where you would like to receive your care and additional
instructions for your decision makers
prefer to die at home with hospice services to support my
I f I am no longer able to take
care of my own personal needs, I would rather be in a nursing home
or other care facility than have my family care for me.
I f is
necessary for me to placed in a nursing home, I would prefer (or
prefer to avoid) ____________________________ (name of nursing
I realize I
may not have much choice over where I receive my care, but I hoe.
Wherever I am, I can look out a window and see the trees and
it is reasonable and correct to consider the cost when making a
decision about any treatment or procedure.
I would like my health
care agent to consult with ___________________ before making any
care on my behalf.
I want my agent to keep
my children informed about my condition.
I ask family members and
friends to support my decisions and those my health care agent makes
on my behalf.
I know that they are many
ďgray areasĒ in end-of-life decision making. I also know that I
cannot anticipate all possible dilemmas that my decision maker(s)
might face. All I ask is that you do your best to figure out what I
would want under circumstances. Thank