For each item, select the number that best describes your situation. Total your scores to get a big picture. Lower scores indicate less manageable situations; higher scores indicate situations that may be more readily managed.
The care receiver:
_____ (1) Has few if any financial assets
_____ (2) Doesn't qualify for government assistance programs
_____ (3) Is financially able to pay for needed support and care
_____ (1) Has no financial assets to give to the patient's care
Did a particular event cause you to make the decision?
Did an article you read in the newspaper or something that happened to a
family member make you think about it?
Is the decision part of a broader effort on your part to prepare for the
end of life, for instance making your last will and testament for distribution
of your property?
What is motivating you to take these actions now?
Sometimes sharing your personal concerns and values, your spiritual beliefs,
or your views about what makes life worth living can be as helpful to your
agent as talking about specific treatments and circumstances. For example:
How important is it to be to be physically independent and to stay in your
own home? Independence can be extremely important to some and maybe less
important to others.
What aspects of your life give it the most meaning?
How important would it be for you to be able to recognize people or
interact with them?
What are your particular concerns about dying? About death?
How do your religious or spiritual beliefs affect your attitudes toward
dying and death? Would you want your agent to take into account the effect of
your illness on any other people?
Should financial concerns enter into decisions about your treatment?
Would you prefer to die at home if possible?
These are not simple questions and your views may change. It is important
that you review these issues with your agent from time to time.
WebMD Medical Reference from the National Hospice and Palliative Care Organization