Advance Care Planning Checklist

Overview

One of the first steps in completing a medical Power of Attorney living will form is to choose at least one person to act as your Health Care Agent. This person will work with your health care provider to make sure your wishes are carried out through a living will in the event you are unable to communicate your own decisions.

Your Health Care Agent(s) will need to know your thoughts and wishes about the kind of medical care you would or would not want. This is not always easy to talk about, and you may not be sure which topics should be discussed. The following checklist covers a variety of advance care planning topics you may wish to discuss with your Health Care Agent to help you create a living will.

Checklist

Medical Treatment

Talk about your wishes concerning the use of the following medical treatments if you were severely ill or injured, suddenly needed hospice or palliative care, or were unable to make health care decisions for yourself:

  • Kidney dialysis – A machine used to cleanse the blood if your kidneys cannot function on their own.
  • Cardiopulmonary resuscitation (CPR) – A procedure to restart circulation if your heart stops beating. It involves repeated pushing on the chest and pushing air into the lungs through the mouth.
  • Respirator or ventilator – A breathing machine if you are unable to breathe on your own.
  • Artificial nutrition – Nourishment provided through a tube that is threaded through the nose into the stomach. For longer periods of feeding, a surgical procedure may be performed to place the feeding tube through the abdomen into the stomach.
  • Artificial hydration – Fluids given through a tube placed in a vein (in your hand, arm, or other location).

Procedures After Death

Talk about your wishes concerning procedures after your death, and be sure to include these topics in your medical Power of Attorney:

  • Organ donation – Organs or tissues of your body can be used after your death to replace the diseased or failed organs of another person.
  • Autopsy – Examination of your body after death to determine the cause of death and changes in the body from disease. Please note that in some cases, the coroner may decide an autopsy is needed.

Your Caregivers

Talk about your thoughts and concerns with involving others in your care:

  • Do you think your doctor will support your wishes and decisions?
  • Do you think your doctor should make the final decision about any medical treatments that you might need?
  • Do you think your family and friends will support your wishes and decisions?

Your Health Care Agent

Share any thoughts or concerns you’d like your Health Care Agent to know about, such as:

  • Your current health status or any medical problems
  • How you feel about receiving short or long term care in a nursing home
  • What will be important to you when you are dying (e.g. physical comfort, pain control, family members present, setting or place, etc.)
  • Your religious beliefs and how they affect your current thoughts/wishes

The information presented is intended for general information and educational purposes. It is not intended to replace the advice of your health care provider. Contact your health care provider if you believe you have a health problem.

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