Values Worksheet

Use these questions to consider as you make decisions and prepare documents concerning your healthcare preferences. You may want to write down your answers and provide copies to your family members and healthcare providers, or simply use the questions as “food for thought” and discussion.

How important to you are the following items? Rate each as: 4 (Very important) 3 2 1 0 (Not important)

Letting nature take its course

Preserving quality of life

Staying true to my spiritual beliefs/traditions

Living as long as possible, regardless of quality of life

Being independent

Being comfortable, and as pain free as possible

Leaving good memories for my family and friends

Making a contribution to medical research or teaching

Being able to relate to family and friends

Being free of physical limitations

Being mentally alert and competent

Being able to leave money to family, friends, or charity

Dying in a short while rather than lingering

Avoiding expensive care

Consider the following questions and add your answers:

What will be important to you when you are dying (e.g. physical comfort, no pain, family members present, etc.)?

How do you feel about the use of life-sustaining measures in the face of terminal illness? Permanent coma? Irreversible chronic illness, such as Alzheimer’s disease?

Do you have strong feelings about particular medical procedures? Some procedures to think about include: mechanical breathing (respirator), cardiopulmonary resuscitation (CPR), artificial nutrition and hydration, hospital intensive care, pain relief medication, chemo or radiation therapy, and surgery.

What limitations to your physical and mental health would affect the health care decisions you would make?

Would you want to have financial matters taken into account when treatment decisions are made?

Would you want to be placed in a nursing home if your condition warranted?

Would you prefer Hospice care, with the goal of keeping you comfortable in your home during the final period of your life, as an alternative to hospitalization?

In general, do you wish to participate or share in making decisions about your health care and treatment? Would you always want to know the truth about your condition, treatment options, and the chance of success of treatments?

Compassion & Choices
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