All PREPARE Questions and Your Answers

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On this page, you can see all PREPARE for Your Care Questions.

You can also go to Your Advance Directive.

Your Advance Directive

The PREPARE for YOUR Care program can put your answers onto a special form called an advance directive.

This form lets you have a say about how you want to be cared for. It can be used to start discussions with family and friends. If the advance directive is signed (this is your choice), it becomes legal and can be used by your medical providers.

Get Your Advance Directive

All PREPARE for YOUR Care Questions

If you answered any questions, your answers are below. You can also answer or change them on this page.

Your Action Plan

What action will you take?

Ask someone to be your medical decision maker

Talk to your family and friends about your medical wishes

Talk to your medical providers about your medical wishes

Put your wishes in writing on an advance directive

I have already done all of these actions

Your Step 1 Answers: Choose a Medical Decision Maker

QUESTION 1:

Can you think of ANY family or friends who MAY be able to make medical decisions for you if you become too sick to make your own decisions?

Yes

I am not sure

QUESTION 2:

Decision Maker #1:

I want this person to make my medical decisions if I am not able to make my own:

First Name

Last Name

Relationship

Decision Maker #2:

If the first person cannot do it, then I want this person to make my medical decisions:

First Name

Last Name

Relationship

2a.

If you want, you can write why you chose your Medical Decision Makers #1 and #2.

2b.

Do you prefer your family and friends make medical decisions for you as a group? If so, who do you want to include in the group?

QUESTION 3:

Is there anyone you would NOT want to make medical decisions for you? If so, write their name and relationship to you here:

QUESTION 4:

When do you want your Medical Decision Maker(s) to make medical decisions for you?

I ONLY want my Medical Decision Maker(s) to make medical decisions for me if I become too sick to make my own decisions.

I want my Medical Decision Maker(s) to make medical decisions for me now, EVEN when I can make my own decisions.

I am not sure

If you want, you can write why you feel this way.

If there are decisions you do not want your Medical Decision Maker(s) to make, write them here:

Review Step 1

Your Step 2 Answers: Decide What Matters Most in Life

QUESTION 1:

What is most important in your life? What matters most?

Knowing what is most important in life can help you decide on medical care that is right for you. Click on as many as you want.

Your family or friends

Your pets

Hobbies, such as gardening, hiking, and cooking: Your hobbies:

Working or volunteering

Caring for yourself and being independent

Not being a burden to your family or friends

Religion or spirituality: Your religion:

Something else

I am not sure

What brings your life joy? What are you most looking forward to in life?

QUESTION 2:

What experience have you had with serious illness?

Have you had your own experience with serious illness?
Do you remember someone close to you who was very sick or dying?
Do you remember seeing someone on TV who was very sick or

Think about what went well, what did not go well, and why.

If you were in these situations, what would you want for yourself?
You may change your mind about how you feel over time.

If you want, you can write why you feel this way.

QUESTION 3:

Which of the options along this line shows how you feel TODAY, in your CURRENT HEALTH about your quality of life and goals for medical care?

If you are not sure, click the I am not sure box.

My main goal is to live as long as possible, no matter what.

Equally important

My main goal is to focus on quality of life and being comfortable.

I am not sure

If you want, you can write why you feel this way.

QUESTION 4:

Do you have religious or spiritual beliefs that guide your medical care?

QUESTION 5:

What if you get memory loss or dementia? How do you want your medical care team, family or friends to talk with you about this? What would you be worried about? What would be important to you?

QUESTION 6:

If you drive, what if you need to stop for your safety? How do you want your medical care team, family or friends to talk with you about this? What would you be worried about? What would be important to you?

QUESTION 7:

What if you could no longer take care of yourself at home? How do you want your medical care team, family or friends to talk with you about this? What would you be worried about? What would be important to you?

QUESTION 8:

If you were in the hospital or very ill, who could help pay your rent or bills? Name(s):

What would be important for people to know about this?

8a.

Do you have pets? Who could take care of your pets? Name(s):

What would be important for people to know about this?

*Note: To give this person legal power to help with these things, you need to also write this in other legal forms. See PlanforClarity.org.

QUESTION 9:

Which of the options along this line shows how you feel about your quality of life and goals for medical care at the END OF LIFE?

Click along this line to show how you feel. If you are not sure, click the I am not sure box.

My main goal is to live as long as possible, no matter what.

Equally important

My main goal is to focus on quality of life and being comfortable.

I am not sure

If you want, you can write why you feel this way.

QUESTION 10:

At the end of life, which of these things would be very hard on your quality of life?

Being in a coma and not able to wake up or talk to my family and friends

Not being able to live without being hooked up to machines

Not being able to think for myself, such as severe dementia

Not being able to feed, bathe, or take care of myself

Not being able to live on my own, such as in a nursing home

Having constant, severe pain or discomfort

Something else

I am not sure

Or, I am willing to live through all of these things for a chance of living longer.

If you want, you can write why you feel this way.

QUESTION 11:

If you were so sick that you may die soon, what would you prefer?

Try all life support treatments that my doctors think might help. I want to stay on life support treatments even if there is little hope of getting better or living a life I value.

Do a trial of life support treatments that my doctors think might help. But, I do not want to stay on life support treatments if the treatments do not work and there is little hope of getting better or living a life I value.

I do not want life support treatments, and I want to focus on being comfortable. I prefer to have a natural death.

I am not sure

11a.

What else should your medical providers and medical decision maker know about this choice? Or, why did you choose this option?

11b.

Are there treatments you know that you would NOT want (like CPR, dialysis, or a feeding tube)? Why do you feel this way?

You may change your mind about how you feel over time.

QUESTION 12:

If you were at the end of life, where would you want to be?

At home

In the hospital

Either

I am not sure

QUESTION 13:

What else would be important at the end of life, such as food, music, pets, religion or spirituality, or people you want around you?

QUESTION 14:

Have you made funeral or burial arrangements? Where can your friends or family find this information?

QUESTION 15:

Have you made a will? Where can your friends or family find this information?

*Note: Wills are other legal forms. See planforclarity.org.

QUESTION 16:

What else should your medical providers and medical decision maker know about you and your choices for medical care?

Review Step 2

Your Step 3 Answer: Choose Flexibility for Your Decision Makers

QUESTION 1:

How much flexibility do you want to give your medical decision maker?

TOTAL FLEXIBILITY: It is OK for your decision maker to change any of your prior medical decisions if the doctors think it is best for you at that time.

SOME FLEXIBILITY: It is OK for your decision maker to change some of your medical decisions if the doctors think it is best. But, some wishes you NEVER want changed even if the doctors recommend it.

NO FLEXIBILITY: Your decision maker must follow all of your medical wishes exactly. It is NOT OK to change your decisions, even if the doctors recommend it.

I am not sure

If you want, you can write why you feel this way.

Review Step 3