Digital Healthcare Values Directive

Complete the digital healthcare values directive form below

What is your name?

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Would you like to name a Medical Decision Maker for when you are not able to speak for yourself? This may be a person who knows your values and can advocate for you.

Yes

Who do you want to be your Medical Decision Maker? (List first and last name below)

What is your Medical Decision Maker's phone number?

Rank the values below based on how important they are to you

Please share any other values you have or other important elements about who you are that you would like to share. An example could be: "I am someone who really values hearing the truth, even if it is hard." If you do not have anything else to say, please type "none to add."

Your sense of self is very important. Chose all that describe what are the most important abilities for you to maintain

Talking and communicating with others verbally

Physically engaging through sense of touch, taste and feel

Ability to walk and move around

Being present and engaged

If there are some specific things you want your providers and caregivers to know about you, feel free to tell us about your hobbies, passions and specific interests you want to make sure are clear regarding your values and what speaks to your quality of life. An example may be: "I love baking and enjoying chocolate treats." If you have none, enter "none to add."

If I end up in a permanent vegetative state or with severe neurologic (brain) damage, I want:

To be kept comfortable, free of pain and allow to die naturally. I want my care to focus on symptom management

To have temporary trial of life extending technologies (up to two weeks) to give me the best chance to recover. If I do not show any meaningful medical improvement, I want to be made comfortable, and allowed a natural death

I want to live as long as I can and to have aggressive interventions as long as they are appropriate and considered beneficial to my recovery

If I am given a terminal diagnosis or in the end-stage of my condition, I want:

To be kept comfortable, free of pain and allow to die naturally. I want my care to focus on symptom management

I want to live as long as I can and to have aggressive interventions as long as they are appropriate and considered beneficial to my recovery

I enjoy eating foods that bring me pleasure. If I am no longer able to take food by mouth, I want:

To be kept comfortable, free of pain and allow to die naturally. I want my care to focus on symptom management

To have a temporary trial of artificial nutrition and hydration (up to two weeks) to give my best chance to recover my ability to eat food by mouth. If I am not able to recover this ability, I want to be made comfortable and allowed a natural death

To have artificial nutrition and hydration for as long as medically appropriate

Do you agree or disagree with this statement?: "If the only way for me to continue living is in the hospital setting on machines, I choose to stop the machines and have a natural death."

Agree

Disagree

I am willing to have aggressive interventions and procedures done only when there is a good chance I will recover or show significant medical improvement within a reasonable amount of time (up to two weeks). If I do not improve, then I want interventions to stop and allow me to have a natural death. This includes ventilators, dialysis, and ECMO

Yes, I want the trial run of aggressive therapies

No, I want to move to comfort care management

Do you practice religion or spirituality? If yes, please share If so please share your religion or spirituality below

Are there any additional requests you would like to add? Here is where you can be more specific if needed. For example: going outside, music requests, specific foods, etc.)

Upload any documents or photos you would want to share that highlight your wishes or celebrate who you are

Upload File

Check all services you would like to add

Hospice

Death Doula

Social Work

Chaplaincy/Religious leadership

Please provide contact information for all providers you want to have access to your Values Directive. Please ensure you provide full name, email and phone number.

If you would like to give any guidance to what you want following your death, please feel free to answer the following questions.

How would you like your remains to be handled? For example, “I would like my remains to be handled in accordance with my religious or cultural beliefs” or, “I would like to donate my body to science.”

What would you like done with your digital footprint and social media accounts? Please provide your decision maker with login details if you have specific requests.

If you have a referral code, enter it here

Signature

The above answers are mine, freely given, and represent my wishes and values. I submit these statements as fact and agree to these terms and conditions. This acceptance and signature will serve as my consent to use this information as my digital healthcare values directive

I accept terms & conditions

Thanks for submitting your digital healthcare values directive!