Healthcare Directive Questionnaire

Standard: If I become incapable of making informed health care decisions, I grant my agent full power and authority to make health care decisions for me, to the same extent that I could make such decisions for myself if I had the capacity to do so, subject to the limitations set forth in this document, and to appoint successor or alternative agent(s) if my agent is unwilling or unable to continue as my agent.

Broader: If I become incapable of making informed health care decisions, I hereby grant to my agent full power and authority to consent, refuse consent, or withdraw consent to any type of health care procedure (including any procedure to maintain, diagnose, or treat any physical or mental condition), or to make any other health care decision, to the same extent that I could if I had capacity to do so, subject to the terms of this instrument. My agent shall exercise this power and authority in accordance with my expressed desires, known to my agent, whether contained in this document or not. Before acting, my agent shall attempt to communicate with me regarding my desires unless such attempt would be futile. If my desires are unknown, then my agent should decide for me, having my best interests in mind.

Primary physician: My agent’s authority shall become effective when my primary physician determines that I am unable to make my own health care decisions.

Physician and another person: My agent’s authority shall become effective only when both my primary physician and [the person you choose], in consultation with each other, agree that I am unable to make my own health care decisions.

Right away: My agent’s authority to make health care decisions for me shall take effect immediately on my signing this directive.

Keep me alive: I express the desire that my life be prolonged to the greatest possible extent without regard for my physical or mental condition, chance of recovery, likelihood of suffering, or expense, and I authorize my agent to consent to whatever medical procedures are necessary to accomplish this end. I trust my agent, who knows my desires well and in whose judgment I have absolute faith, to exercise their discretion in a manner that would be satisfactory to me.

Don't prolong my dying: If I have an incurable or irreversible physical or mental condition, even if I am not in a persistent vegetative state or some other form of permanent unconsciousness, I want care and treatment that will enable me to take part in activities of daily living, to eat and drink, and to communicate meaningfully with others. I want to live my life with dignity and for my loved ones to have pleasant memories of my final days. Thus, I wish to be allowed to die without prolonging my death with medical treatment [, including artificial nutrition and hydration and cardiopulmonary resuscitation,] that will not benefit me.

Terminal condition: If I should have an incurable injury, disease, or illness certified by [number] physicians to be a terminal condition, and if the application of life-sustaining procedures would serve only to artificially prolong the moment of my death, and if my treating physician determines that my death is imminent whether or not life-sustaining procedures are utilized, then I desire that all life-sustaining treatment be withheld or removed.

Coma: If I am in a coma and have been for at least [number] days and [number] qualified physicians familiar with my condition have diagnosed it as irreversible (i.e., if there is no reasonable possibility that I will regain consciousness), then I desire that all life-sustaining treatment be removed or withheld.

Burdens outweigh benefits: If in my agent’s judgment the burdens of the proposed treatment outweigh the expected benefits, then I desire that all life-sustaining treatment be withheld or withdrawn. I desire that my agent consider relief from suffering, preservation or restoration of functioning, and the quality as well as the extent of the life being preserved when decisions are made concerning life-sustaining care, treatment, services, and procedures.

No reasonable hope: If the extension of my life would result in a mere biological existence, without cognitive function and with no reasonable hope for normal functioning or interaction with my loved ones, then I do not desire any form of life-sustaining procedures [, including nutrition and hydration unless necessary for my comfort or to reduce pain,] or, if life-sustaining treatment has been started or instituted, I desire that it be stopped. It is my desire that my agent consider relief from suffering, preservation or restoration of functioning, and the quality as well as the extent of the life being preserved when decisions are made concerning life-sustaining care, treatment, services, and procedures. In making the decision to withhold or remove treatment, my agent should ask the question “Will the proposed treatment help me recover or will it only prolong my dying?” The determination of what will help me recover, or what will only prolong my dying, shall be made exclusively by my agent.

Continue: Regardless of my condition, it is my desire to receive nutrition and hydration in all ways possible.

Only for a short time: I do not want artificial nutrition and hydration under any circumstances except for the treatment of a temporary condition in which I am unable to eat or drink and then only for a short time. If, within a short period (as determined by my agent after consultation with my physician), there is no benefit to me, then I instruct that artificial nutrition and hydration be withdrawn.

Only for comfort: I do not want artificial nutrition and hydration unless necessary for my comfort or to alleviate pain.

Exact wording: If I develop Alzheimer’s disease or another form of dementia, I would like all noninvasive life-prolonging treatments such as artificial nutrition, fluids, and antibiotics as long as I have the ability to meaningfully interact with my family and friends and am physically independent, but I do not want highly intrusive treatments such as CPR, insertion of a pacemaker or replacement of a pacemaker battery, force feeding, mechanical ventilation, or kidney dialysis. However, if my [the person you choose] determines that I have lost the capacity for meaningful interaction and physical independence, I then want only treatments that would make me more comfortable and free from pain. I would then not want artificial hydration or nutrition or antibiotics.

Exact wording: Although I do not wish to have life-sustaining treatment or procedures if my life would be a mere biological existence, without cognitive functioning, so that I would not recognize my surroundings or my loved ones, I do not wish treatment to be withdrawn prematurely because of money. Thus, if I am in a managed care environment or if my health care provider’s policy results in my health care being reduced or rationed, then I authorize my agent to use my funds to pay for my care or to ask my family and children for money to pay for my care. I further authorize my agent to require treatment and procedures near the end of my life if my agent determines that this treatment is withheld or withdrawn solely for financial reasons.