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Sample Language for Health Care Directives
Most health care directive forms have a place or places where you may write instructions or statements about your health care preferences. This handout makes reference to the Minnesota Health Care Directive form, but the sample statements could be used on any health care directive form.
The sample statements on this handout represent a variety of values, beliefs and preferences. We offer these statements not to support or promote any of them, but rather to help you think about how to express your own values, beliefs and preferences.
General Statements about Feelings, Values and Preferences
The Minnesota Health Care Directive form has places for general statements in several places: page 3 of the Minnesota Health Care Directive and pages 2, 3 and 4 of the “My Health Care Instructions” insert.
v I have lived a good, long life. I am not afraid to die. If I am near death, I do not want any treatments or procedures that will only prolong my life rather than make it better.
v Any decision about my care should be based on the quality of life it is likely to preserve. I would not want my life extended if I could not understand what was going on around me or recognize and interact with the people I love.
v I believe that every human being is valuable, even if he or she is not aware of surroundings and cannot interact with other people. So, even if I become mentally incapacitated, I wish to be given the benefit of any treatment or care that will extend or improve my life.
v I believe that life is sacred and that we should do everything we can to preserve it. If a choice had to be made between keeping me alive and keeping me comfortable, I believe I would always choose to be kept alive, even if that meant that I had to endure pain.
Statements about Pain Control
The Minnesota Health Care Directive “My Health Care Instructions” insert has a place to indicate how important pain control is to you. If you wish to include additional instructions or statements about pain control, you may do so in several places on the insert: the box at the bottom of page 1; the box at the top of page 3; and the “Additional Health Care Instructions” box on page 4.
v Because I watched my own father die in excruciating pain, it is my wish that good pain control be the first item of business in my care. I do not want to have to spend my last days (or weeks, or hours) in pain. I would much prefer to be sedated and die peacefully.
v I believe that pain is part of life. I would rather experience pain than be so “out-of-it” that I can’t interact with the people I care about.
v I believe that if God gives us pain, He has a reason. I do not want to be drugged to the point that I don’t feel pain.
v I hope that pain and other unpleasant symptoms can be kept to a minimum. I’d rather be awake and aware for the last precious days of life, unless I’m in too much pain or discomfort to enjoy them anyway.
Statements about Life-sustaining Procedures
The Minnesota Health Care Directive form has space for statements about specific treatment preferences on page 2 of the insert.
Ventilator/Respirator
v Life would not be worth living if I had to be kept on a respirator indefinitely.
v I have no objection to the temporary use of a respirator or ventilator to keep me alive until I resume breathing on my own.
v If I am close to death, I do not want to be put on a respirator or ventilator for any reason. If such treatment has been started, I wish to have it discontinued.
Artificial Nutrition and Hydration
v I understand that when a person is dying, the body processes slow down and eventually cease. When this happens to me and I can no longer take food or fluids by mouth, I do not want food or fluids by artificial means (tube or intravenous).
v I believe that food and water are not medical treatment, but basic necessities. I want food and water provided by whatever means are necessary to keep me alive.
v I want CPR under any circumstances.
v If I have an incurable terminal illness or injury and my physician judges that I will live only a week or less, even if lifesaving treatment or care is provided to me, I do not want CPR.
Religious and Spiritual Beliefs
The Minnesota Health Care Directive form has a place for statements of religious or spiritual belief on page 3 of the insert.
v I would prefer to be cared for in a (Lutheran, Catholic, Jewish, non-sectarian) home.
v If possible I wish to be present for religious services and have visits from my minister/priest/rabbi even if I do not appear to understand or cannot fully participate.
v I want my family and friends to know that because of my faith I believe that I will be going to a better place when I die. So, if I’m “seeing the light,” I don’t want them to try and bring me back!
v I do not want anyone visiting me to pray for my sins or to try and convert or save me.
General Statements about Treatments to Support or Prolong Life
The following statements could be written on page 3 of the insert under “Feelings About Quality and Length of Life.”
v Do not start or continue life-sustaining procedures if my condition is unlikely to improve and I am not expected to return to full independent functional capacity.
v Even if I am likely to die within a few weeks or have an irreversible condition that so debilitates me that I can no longer appreciate the people and events in my daily life, I want any treatment that would preserve my life or that could cure, improve, or reduce or prevent deterioration in my physical or mental condition.
Other Statements about Care
On page 4 of the insert you may state your preferences about where you want to receive care and leave additional instructions for your decision makers.
v I would prefer to die at home with hospice services to support my caregivers.
v If I am no longer able to take care of my own personal needs, I would rather be in a nursing home or other care facility than to have my family have to care for me.
v If it is necessary for me to be placed in a nursing home, I would prefer (or prefer to avoid) ______________________ (name of nursing home).
v I realize I may not have much choice over where I receive my care, but I hope, wherever I am, I can look out a window and see trees and sky.
v I believe it is reasonable and correct to consider the cost when making a decision about any treatment or procedure.
v I would like my health care agent to consult with ________________ before making any care decision on my behalf.
v I want my agent to keep my children informed about my condition.
v I ask family members and friends to support my decisions and those my health care agent makes on my behalf.
v I know that there are many “gray areas” in end-of-life decision-making. I also know that I cannot anticipate all the possible dilemmas that my decision maker(s) might face. All I ask is that you do your best to figure out what I would want under the circumstances. Thank you.
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