Advanced Care Planning

Step 2: Assess Your Values

Everyone is unique in how they view life and what is most important to them. The following tables will help you determine which values are most important in your life and can help guide future decisions. Rate each item on its importance to you.

Rate the following values from 1 (least important) to 5 (most important).

Medical Values

I want to...
1
2
3
4
5

Be mentally alert and recognize loved ones.

Reduce my pain with medication, even if there are some side effects.

Eat and enjoy food naturally, not by artificial or medical means.

Know all options with my condition.

Know what will happen to my body over time with my disease.

Have tried every medical treatment possible.

Be involved with research studies, even if just to help others.

Live every day possible, no matter the condition of my body.

Have mechanical assistance to help me breathe if I cannot breathe on my own.

Have my organs donated.

Step 1

Personal Values

I want to...
1
2
3
4
5

Maintain my dignity.

Not have to live in a nursing home.

Be able to reasonably perform my normal daily activities.

Pass on words of advice and guidance.

Have my family not argue.

Make sure my affairs are in order to minimize the effect on loved ones.

Talk openly about fears/anxieties.

Ask for forgiveness.

No medical treatments with extreme measures.

Include consideration of religious traditions, beliefs and practices.

Make sure I accomplish important life goals.

Receive support from my pastor, rabbi or clergy.

Values About Death

I want to...
1
2
3
4
5

Have family with me/not die alone.

Be able to say goodbye to loved ones.

Die at home.

Die in the hospital.

Have a natural death, not hooked to tubes or machines.

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