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 form.

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 Preferences

General Statements

¨     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 better.

¨     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 love.

¨     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 Control

Pain management and other additional Health Care Instructions

¨     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 peacefully.

¨     I believe that pain is a part of life. I would rather experience pain than be so “out-of-it” that I can’t 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 don’t feel pain.

¨     I hope that pain and other unpleasant symptoms can be kept to a minimum. I’d rather be awake and aware for the last precious days of life, unless I’m in too much pain or discomfort to enjoy them anyway.

Statements about Life-sustaining Procedures

Statements about specific treatment preferences

Ventilator/ Respirator

¨     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 breathing.

¨     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 discontinued.

Artificial 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 intravenous).

¨     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 alive.

Cardiopulmonary Resuscitation (CPR)

¨     If death is imminent, I do not want CPR.

¨     I want CPR under any circumstances.

¨     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 CPR.

Religious and Spiritual Beliefs

Statements of religious or spiritual beliefs

¨     I would prefer to be cared in a _______________ home.

¨     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 participate.

¨     I want my family and friends to know that because of my faith, I believe that I’ll be going to a better place when I die. So if I’m near passing, I don’t 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 me.

General Statements about Treatments to Support or Prolong Life

Feelings about Quality and Length of Life

¨     Do not 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.

Other Statements about Care

Your preferences about where you would like to receive your care and additional instructions for your decision makers

¨     I would prefer to die at home with hospice services to support my caregivers.

¨     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 home).

¨     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 sky.

¨     I believe 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 “gray areas” 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 You.