Other Side

Your information entered here will be included on the final copy of your Dementia Advance Directive (addendum).

Name

First

Last

Birth Date

Let's get started.

If my physician or health care provider has determined my dementia has progressed to advanced or late stage, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I require around-the-clock (24 hour) assistance and supervision, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I no longer recognize my loved ones, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to walk or move safely without assistance from a caregiver then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to bathe and clean myself without assistance from a caregiver, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to remain at home and have to live in a nursing facility, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I no longer have control of my bladder (urinary incontinence) or bowels (bowel or fecal incontinence), then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am no longer aware of my surroundings (where I am, the date/year, who is with me), then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to clearly communicate my thoughts or needs (words and phrases do not make sense), then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

thoughts progressed If

If my physician or health care provider determines I have six months or less to live, then:

I am interested in Hospice Care to support me and my loved ones. I would like to enroll as soon as I am eligible
I am not interested in hospice
I am unsure at this time. My surrogate can make that decision on my behalf when the time comes.

If the changes caused by dementia result in any of the following:

I no longer appear to desire food or drink, turn my head, or otherwise avoid being fed or given fluids
I do not open my mouth to accept food or drink without prompting, and all food or drink must be provided by a caregiver (hand or spoon-feeding)
I am unable to safely swallow food or drink (cough, choke, or aspirate/inhale)
The negative consequences of continued food or drink, as determined by a medical provider, outweigh the benefits

Learn more about nutrition support and artificial hydration

Then I request all food and drink be stopped, including nutrition support and hydration

Dementia is unpredictable and different for everyone. My hope is:

This document will help guide my medical team and surrogate decision maker(s). I authorize them to be flexible and make decisions based on what they feel is in my best interest.
This document should serve as clear and precise direction to my medical team and surrogate decision maker(s). My wishes should be followed as much as possible, even if they would personally prefer another option.

Additional thoughts and considerations

Please note any additional information that is important to you. For example, do you have additional wishes that were not included in the document? Is there any person you would not want to be consulted about your care? Would you want your representative to advocate for hospice and the possibility of palliative sedation if you are experiencing severe distress or pain?

Additional info

Yo estoy completando este documento porque quiero que mi(s) persona designada (s) en la toma de decisiones, médicos y equipo de atención médica, familia, cuidadores y seres queridos conozcan mis deseos respecto al tipo de cuidados que deseo si vivo con demencia.

con entonces ya

Nombre

First

Last

Fecha de nacimiento

Let's get started.

Si mi médico o profesional de atención médica ha determinado que mi demencia ha progresado a una fase avanzada o final, entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si necesito asistencia y supervisión las 24 horas del día, deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si ya no reconozco a mis seres queridos, entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si no puedo caminar o moverme con seguridad sin ayuda de un cuidador, entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si no puedo bañarme y asearme sin ayuda de un cuidador, entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si no puedo quedarme en casa y debo vivir en un hogar para ancianos, entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si ya no controlo la vejiga (incontinencia urinaria) o los intestinos (incontinencia intestinal o fecal), entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si ya no soy consciente de lo que me rodea (dónde estoy, la fecha/año, quién está conmigo), entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si no soy capaz de comunicar claramente mis pensamientos o necesidades (las palabras y frases no tienen sentido), entonces deseo

Vivir tanto como sea posible
Tratarme pero no de forma agresiva
Permitir una muerte natural

Si mi médico o profesional de atención médica determina que me quedan seis meses o menos de vida, entonces

Me interesan los cuidados de hospicio para ayudarme a mí y a mis seres queridos. Me gustaría inscribirme lo más pronto posible en lo que sea elegible.
No estoy interesado en cuidados de hospicio.
No estoy seguro en este momento. Mi sustituto en la toma de decisiones puede decidir por mí cuando llegue el momento

Si los cambios causados por la demencia provocan algo de lo siguiente:

Parece que ya no deseo comer ni beber (giro la cabeza, escupo la comida, no abro la boca).
Dependo de otra persona para que me proporcione toda la comida y bebida (también conocido como alimentación a mano o con cuchara).
No puedo tragar alimentos o con seguridad (toso, me atraganto o aspiro/inhalo)
Las consecuencias negativas de seguir comiendo o bebiendo, determinadas por un médico, son mayores que los beneficios.

Entonces solicito que se deje de darme de comer y beber, incluyendo el apoyo nutricional y de hidratación.

La demencia es imprevisible y es diferente para cada persona. Mi esperanza es que:

Este documento ayudará a orientar a mi equipo médico y a mi(s) persona(s) designada(s) en la toma de decisiones. Les autorizo a ser flexibles y a tomar decisiones en función de lo que consideren que es mejor para mí.
Este documento debe servir de orientación clara y precisa a mi equipo médico y a la persona o personas designadas en la toma de decisiones. Deben seguirse mis deseos en la medida de lo posible, aunque personalmente prefieran otra opción.

Información adicional importante para usted

Por ejemplo, ¿tiene otros deseos que no se hayan incluido? ¿Hay alguna persona a la que no desea se le consulte sobre sus cuidados? ¿Le interesan los ensayos clínicos (si es elegible)? ¿Le gustaría que su representante solicite cuidados de hospicio y la posibilidad de sedación paliativa en caso de que usted sufra angustia o dolor severos?

Additional info

Your information entered here will be included on the final copy of your Dementia Advance Directive (addendum).

Name

First

Last

Birth Date

Let's get started.

If my physician or health care provider has determined my dementia has progressed to advanced or late stage, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I require around-the-clock (24 hour) assistance and supervision, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I no longer recognize my loved ones, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to walk or move safely without assistance from a caregiver then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to bathe and clean myself without assistance from a caregiver, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to remain at home and have to live in a nursing facility, then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I no longer have control of my bladder (urinary incontinence) or bowels (bowel or fecal incontinence), then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

am then to

If I am no longer aware of my surroundings (where I am, the date/year, who is with me), then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If I am unable to clearly communicate my thoughts or needs (words and phrases do not make sense), then I want to:

Live as long as possible
Treat me, but not aggressively
Allow a natural death

If my physician or health care provider determines I have six months or less to live, then:

I am interested in Hospice Care to support me and my loved ones. I would like to enroll as soon as I am eligible
I am not interested in hospice
I am unsure at this time. My surrogate can make that decision on my behalf when the time comes.

If the changes caused by dementia result in any of the following:

I no longer appear to desire food or drink, turn my head, or otherwise avoid being fed or given fluids
I do not open my mouth to accept food or drink without prompting, and all food or drink must be provided by a caregiver (hand or spoon-feeding)
I am unable to safely swallow food or drink (cough, choke, or aspirate/inhale)
The negative consequences of continued food or drink, as determined by a medical provider, outweigh the benefits

Learn more about nutrition support and artificial hydration

Then I request all food and drink be stopped, including nutrition support and hydration

Dementia is unpredictable and different for everyone. My hope is:

This document will help guide my medical team and surrogate decision maker(s). I authorize them to be flexible and make decisions based on what they feel is in my best interest.
This document should serve as clear and precise direction to my medical team and surrogate decision maker(s). My wishes should be followed as much as possible, even if they would personally prefer another option.

Additional thoughts and considerations

Additional info

Sign Up To Get Involved

Learn More And Get Involved

Medical Aid-in-Dying FAQs

Start Planning Your End-of-Life Care

Take Action: Demand Action from Your Lawmakers

About The Film

Additional thoughts and considerations

Información adicional importante para usted

Additional thoughts and considerations