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My Toolkit

My Wishes for Medical Care


Three things are required to have maximum control over medical care at the end of life, and they are the same whether death is sudden or well-anticipated.

1) You must consider what you would want under common medical scenarios.
2) You must communicate these wishes to other people, or at least one other person.
3) You must designate someone who understands your wishes to carry them out and make medical decisions if you cannot speak for yourself. This person, and it should be only one, may be called “surrogate”, “healthcare power of attorney”, “healthcare proxy”, or “healthcare agent”. State laws vary on names and definitions. More about that in the “Legal and Financial” Section.

There are two things occurring in health care facilities every day that most of us claim not to want when we can no longer make our own decisions and are unlikely to ever again live what we believe to be a quality existence:

1) Being put on a ventilator or breathing machine with no end in sight.

2) Being kept alive by artificial nutrition and hydration through a feeding tube with no end in sight.

This Section contains three forms which (after purchase) would be your forms. You can fill them in at your leisure and edit them endlessly. They can be saved, printed, emailed or accessed through Final Roadmap to anyone to whom you permit access. If you do not permit access, they cannot be viewed.

The forms are designed to help you think through common medical decisions and situations that relate to the end of life. They will be useful if you complete them to your satisfaction and distribute them to your healthcare power of attorney, physician and loved ones. These forms can become part of your legal advance directives. They will be more useful if you talk about their contents with your surrogate decision maker(s). No doubt, beginning this conversation is awkward, as no one wants to think about getting in a terrible accident, becoming seriously ill or dying. Actually, the younger and healthier you are, the easier it is to discuss, because death is typically abstract. As we age or have life compromised by illness, death is less abstract and the conversation becomes even more important. Final Roadmap offers suggestions for initiating the conversation.

My Intentions for Medical Care Form

Excerpted questions with sample responses (actual forms do not include responses).

Limitations on Preservation of Life Questions Answers Notes
Artificial Breathing If you are not progressing toward an acceptable quality of life as you have defined it, are there a number of weeks at which you would like life-prolonging treatments like artificial ventilation withdrawn? Two weeks. If, I’m not getting better, or it is unlikely I will ever breathe on my own I want to be taken off the ventilator. If all of my children want to be present as the machine is disconnected, up to five days may be added to the two weeks.
Artificial Nutrition and Hydration (ANH) If you are not progressing toward an acceptable quality of life as you have defined it, for how long do you with ANH to be administered? One month or sooner if it is determined I will never again be able to eat and drink by mouth and/or be able make my own medical decisions.  



Questions My Surrogate Should Ask

A surrogate is a person, and it should be just one, who you authorize to make healthcare decisions when you are not able to do so. The choice of a surrogate is the single most important decision you will make in considering end of life. You want a person who is:

  • Absolutely committed to carrying out your wishes, whether or not he/she agrees.
  • Strong enough ethically and emotionally to resist pressure from others who may not agree with your wishes.
  • Comfortable enough in healthcare settings to be your advocate, and not overly intimidated by medical personnel and settings.


Questions My Surrogate Should Ask Form

Excerpted questions with sample responses (actual forms do not include responses).

Question If the answer is My Intention
What is the likelihood that s/he will return to the state s/he was in before this latest episode? Totally unlikely Ask if I will return to a quality of life I consider acceptable and go from there.
  I don’t know Set a time limit of one week. If there is no positive progress, withdraw all treatment including ANH
  At least a 50/50% chance Go for it - try anything and everything for a month, then reevaluate.

My Intentions for Organ Donation 

Organ, tissue and whole body donation are decisions which must be reinforced at the time of death by your surrogate or your designated Power of Attorney for Healthcare. It is important that they know and will respect your wishes.

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