- On a scale of 1 to 5, where do you fall on this continuum?
I’m not sure or
1
|
2
|
3
|
4
|
5
|
Let me die in my own bed, without any medical intervention
|
Don’t give up on me no matter what, try any proven and unproven intervention possible
|
- If there were a choice, would you prefer to die
at home, or
in a hospital?
I’m not sure
- Could a loved one correctly describe how you’d like to be treated in the case of a terminal illness?
Yes, or
No
- Is there someone you trust whom you’ve appointed to advocate on your behalf when the time is near?
Yes, or
No
- Have you completed any of the following: written a living will, appointed a healthcare power of attorney, or completed an advanced directive?
Yes, or
No
Please print this out to help aid in your discussion with your loved ones!
Note: We hope to encourage discussion through these questions. The answers you provide do not constitute a legally binding living will or advanced directive.