Dear Doctor

Please answer some simple questions in the form below. After completing this form, you will be able to print/email two documents:

(a) A pre-filled advance directives form: You can print and sign and give one copy to your doctor and keep a copy for yourself and your loved ones.

(b) A letter to your doctor that expresses your values, wishes and preferences about care you wish to receive in the future when you are in the last chapter of your life.

My Doctor's name

RE: What matters most to me at the end of my life.

I have been reading and thinking about end-of-life issues lately. I realize how important it is that I communicate my wishes to you and my family. I know that you are very busy.

You may find it awkward to talk to me about my end-of-life wishes or you may feel that it is too early for me to have this conversation. So I am writing this letter to clarify what matters most to me.

My name

What Matters Most to Me
Examples: Being at home, doing gardening, going to church, playing with my grandchildren

My important future life milestones
Examples: my 10th wedding anniversary, my grandson's high school graduation, birth of my granddaughter

Here is how we prefer to handle bad news in my family
Examples: We talk openly about it, we shield the children from it, we do not like to talk about it, we do not tell the patient

Here is how we make medical decisions in our family
Examples: I make the decision myself, my entire family has to agree on major decisions about me, my daughter who is a nurse makes the decisions etc.

Here is who I want making medical decisions for me when I am not able to make my own decisions
1
Relationship
Address
Phone

2
Relationship
Address
Phone

3
Relationship
Address
Phone

What I DO NOT want at the end of my life
If my heart were to stop beating, do NOT attempt to restart it
I do not want to be on a breathing machine
I do not want artificial liquid feeding
I do not want dialysis
I do not want to spend my last days in a hospital
I do not want to die at home
Other

What I DO WANT at the end of life
I want to be pain free
I want to spend my last days in the hospital
I want you to help me die gently and naturally
I want to die at home
I want hospice care
Other

If my pain and distress are difficult to control, please sedate me (make me sleep with sleep medicines) even if this means that I may die sooner
Yes
No

What to do when my family wants you to do something different than what I want for myself?
I am asking you to show them this letter and guide my family to follow my      wishes
I want you to override my wishes as my family knows best

Which of the following do you choose?
I want to make my health decisions as long as I am able to.
I want my surrogate (family member/friend I identify) to make medical decisions for me, starting now.

After a person passes away, their organs and tissues(eyes, kidneys, liver, heart, skin etc.) can be donated to help other people who are ill.

Choose one of the following

I will donate any of my organs and tissues after I pass away.
I will donate the following organs, tissues only

I do NOT want to donate my organs or tissues after I pass away
I do NOT want to decide now. My proxy can decide after I pass away.

Other information you want to convey