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Instructions To help others make sense out of your answers, think about the following questions
and be sure to explain your answers to your loved ones and health care providers.
If you checked “worth living, but just barely” for more than one factor, would a combination of these
factors make your life “not worth living?” If so, which factors?
If you checked “not worth living,” does this mean that you would rather die than be kept alive?
If you checked “can’t answer now,” what information or people do you need to help you decide?
a. I can no longer walk but get around in a wheelchair.
b. I can no longer get outside—I spend all day at home.
c. I can no longer contribute to my family’s well being.
d. I am in severe pain most of the time.
e. I have severe discomfort most of the time (such as
nausea, diarrhea, or shortness of breath).
f. I rely on a feeding tube to keep me alive.
g. I rely on a kidney dialysis machine to keep me alive.
h. I rely on a breathing machine to keep me alive.
i. I need someone to help take care of me all of time.
j. I can no longer control my bladder.
k. I can no longer control my bowels.
l. I live in a nursing home.
m. I can no longer think clearly-I am confused all the time.
n. I can no longer recognize family/friends
o. I can no longer talk and be understood by others.
p. My situation causes severe emotional burden for my
family (such as feeling worried or stressed all the time).
q. I am a severe financial burden on my family.
r. I cannot seem to “shake the blues.”
s. Other (write in):
That’s a sobering list of questions...