Patient Values Questionnaire

The following questions can help you think about your values as they relate to medical care decisions. You may use the questions to discuss your views with your health care agent and others, or you may write answers to the questions as a help to your agent and health care team. (If you fill out this worksheet and want it to be part of your DPA/HC, sign it in the presence of witnesses and attach it to your DPA/HC form.)

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 person's 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:

5. Could you imagine reasons for temporarily accepting medical treatment for the conditions you have described? What might they be?

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

7. What if your chances of recovery were poor (less than one 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? What are they?

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

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 these situations? If so, describe:

Date: ______________ Signature: ________________________________ Date of Birth: ____________

Address: ____________________________________________________________________________

Witness: __________________________________ Witness: __________________________________