Handbook for Mortals : Planning Ahead : Values History Questionnaire

One way to approach the kinds of choices involved with end-of-life care is to consider the questions on a values history questionnaire. Picture of a dying man talking with a woman caregiver These are not questions that you may have seen on a living will. Your answers will not be simple "yes's" or "no's." While this questionnaire may look complicated, it can help you to talk about your wishes with someone who may have to make decisions for you when you cannot. Filling out a questionnaire like this will help you think about how you hope things will be. Your answers will also be a useful way to get started talking with your family.

1. What do you value most about your life? (For example: living a long life, living an active life, enjoying the company of family and friends, etc.)

2. How do you feel about death and dying? (Do you fear death and dying? Have you experienced the loss of a loved one? Did that personís illness or medical treatment influence your thinking about death and dying?)

3. Do you believe life should always be preserved as long as possible?

4. If not, what kinds of mental or physical conditions would make you think that life-prolonging treatment should no longer be used? Being:

  • Unaware of my life and surroundings
  • Unable to appreciate and continue the important relationships in my life
  • Unable to think well enough to make everyday decisions
  • In severe pain or discomfort

5. Could you imagine reasons for temporarily accepting medical treatment for the conditions you described?

6. How much pain and risk would you be willing to accept if your chances of recovery from an illness or an injury were good (50-50 or better)?

7. What if your chances of recovery were poor (less than 1 in 10)?

8. Would your approach to accepting or rejecting care depend on how old you were at the time of treatment? Why?

9. Do you hold any religious or moral views about medicine or particular medical treatments?

10. Should financial considerations influence decisions about your medical care?

11. What other beliefs or values do you hold that should be considered by those making medical care decisions for you if you become unable to speak for yourself?

12. Most people have heard of difficult end-of-life situations involving family members or neighbors or people in the news. Have you had any reactions to those situations?

Adapted from the Vermont Ethics Network.

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Keywords: Advance care planning
Handbook for Mortals book cover Copyright © 1999, 2006 by Joanne Lynn. This extract from the Handbook for Mortals by Joanne Lynn, M.D. and Joan Harrold, M.D. is used with permission. To learn more about improving care at the end of life visit the main web site for Americans for Better Care of the Dying.
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