A Values History Form recognizes that medical decisions we make for ourselves are based on those beliefs, preferences and values that matter most to us: How do we feel about our overall health? What personal relationships in our lives are important to us? How do we feel about independence or dependence? About pain, illness, dying and death? What are our goals for the future?
A discussion of these and other values can provide important information for those who might, in the future, have to make medical decisions for us when we are no longer able to do so.
Furthermore, a discussion of the questions asked on the Values History Form can provide a solid basis for families, friends, physicians and others when making such medical decisions. By talking about these issues ahead of time, family disagreements may be minimized. And when such decisions do need to be made, the burden of responsibility may be lessened because others feel confident of your wishes.
There are a number of ways in which you might begin to answer these questions. Perhaps you would like to write out some of your thoughts before you talk with anyone else. Or you might ask family and friends to come together and talk about your - and their - responses to the questions.
Often, simply giving copies of the Extended Values History Form to others is enough to get people talking about a subject that, for many of us, is difficult and painful to consider.
The most important thing to remember is that it is easier to talk about these issues BEFORE a medical crisis occurs. Feel free to add questions and comments of your own.
Make sure that all those who might be involved in your health care are aware of you wishes: family, friends, physicians and other health care providers, your Pastor, your lawyer. If appropriate, give written copies to these people. But remember, each of us continues to grow and change, and so the Extended Values History Form should be discussed and updated fairly regularly.
Consider attaching a copy of it to your Living Will, if you have one, or filing it with important medical papers.
Everyone. While we often focus on older people, it is just as important that younger people discuss these issues and make their wishes known. Some of the most difficult medical decisions must be made on behalf of younger patients. If they had talked with families and friends, decision makers could feel they were following the patient's wishes.
We hope this Extended Values History Form is of help to you, your families and friends. Many people have commented that it is important to reflect, not so much on How I want to die, but rather on How I want to LIVE until I die.
It is important that your medical treatment be your choice. The purpose of this form is to assist you in thinking about and writing down what is important to you about your health. If you should at some time become unable to make health care decisions, this form may help others make a decision for you in accordance with your values.
The main section of this form provides an opportunity for you to discuss your values, wishes, and preferences in a number of different areas, such as your personal relationships, your overall attitude towards life, and your thoughts about illness. Towards the end of the form is a space for indicating whether you have completed an Advance Directive (Living Will) and where such documents may be found.
The Extended Values History Form is not copyrighted. You are encouraged to make additional copies for friends and relatives to use.
D.O.B.: Today's Date:
If someone has assisted you in completing this form, please fill in his or her name, address, and relationship to you:
What would you like to say to someone reading this document about your overall attitude towards life?
What goals do you have for the future?
How satisfied are you with what you have achieved in your life?
What, for you, makes life worth living?
What do you fear most? What frightens or upsets you?
What activities do you enjoy (eg hobbies, watching TV)?
How would you describe your current state of health?
If you currently have any health problems or disabilities, how do they affect: You? Your family? Your work? Your ability to function?
If you have any health problems or disabilities, how do you feel about them?
What would you like others (family, friends, doctors) to know about this?
Do you have difficulty in getting through the day with activities such as: eating? preparing food? sleeping? dressing and bathing? etc.
What would you like to say to someone reading this document about your general health?
What role do family and friends play in your life?
How do you expect friends, family and others to support your decisions regarding medical treatment you may need now or in the future?
Have you made any arrangements for family or friends to assist in making medical treatment decisions on your behalf? If so, who has agreed to assist in making decisions for you and in what circumstances?
What general comments would you like to make about the personal relationships in your life?
How does independence or dependence affect your life?
If you were to experience decreased physical and mental abilities, how would that affect your attitude toward independence and self-sufficiency?
If your current physical or mental health gets worse, how would you feel?
Have you lived alone or with others over the last 10 years?
How comfortable have you been in your surroundings?
How might illness, disability or age affect this?
What general comments would you like to make about your surroundings?
What is your spiritual/religious background?
How do your beliefs affect your feelings towards serious, chronic or terminal illness?
How does your faith community, church or synagogue support you?
What general comments would you like to make about your beliefs?
How do you relate to your doctors? Please comment on: trust; decision making; time for satisfactory communication; respectful treatment.
How do you feel about other caregivers, including nurses, therapists, chaplains, social orkers etc?
What else would you like to say about doctors and other caregivers?
What general comments would you like to make about illness, dying and death?
What will be important to you when you are dying (eg, physical comfort, no pain, family members present etc)?
Where would you prefer to die?
How do you feel about the use of life-sustaining measures if you were: suffering from irreversible chronic illness (eg Alzheimer's disease)? terminally ill? in a permanent coma?
What general comments would you like to make about medical treatment?
What general comments would you like to make about your finances and any costs connected with your health care?
What are your feelings about having enough money to provide for your care?
What general comments would you like to make about your funeral and burial or cremation?
Have you made your funeral arrangements? If so, with whom?
How would you like your obituary (announcement of your death) to read?
Write yourself a brief eulogy (a statement about yourself to be read at your funeral).
What would you like to say to someone reading this Extended Values History Form?
Have you signed a Living Will?Yes No
Where can it be found?
Copyright © 1995 HTML markup Chris
Docker. The values history form may be freely reproduced for personal use.
Acknowledgement should be made if it is reproduced in any form. Print the
form and adapt it for your own use, but bear in mind it should be printed
in such a way that it is easy to read, eye-catching, and durable. A suitable
printed version is also available as one of the items in the Exit Living WIll Pack.