My BestEndings Advance Directives (Living Will) If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required Who am I? My Health Comfort Care Quality of Life Pause for Thought DNR Medical Interventions Brain Function Evaluation Confirm/Share Step 1: Which of these quotes best represent your wishes: “Do not go gentle into that good night, Old age should burn and rage at close of day; Rage, rage against the dying of the light.” – Dylan Thomas“I’ve told my children that when I die, to release balloons in the sky to celebrate that I graduated: for me death is a graduation.” – Elizabeth Kubler Ross“To the organized mind, death is but the next great adventure.” – JK Rowling“Miss me, but let me go, for this is a journey we all must take” – Amy Louise Kerswell Step 2: How's your health now? Many people live with one or more health issues, and still consider themselves healthy. Examples of chronic illness diabetes, arthritis, rheumatoid disease, Crohn’s disease, heart disease, mental illness, asthma, digestion, kidney disease, diabetes. Examples of terminal or life-limiting illness Dementia, Parkinson’s, ALS, MS, some cancers, Kidney Failure, Lung Disease, How would you describe your current health? (check all that apply) I describe myself as: (check all that apply) HealthyIn good healthLiving with chronic illnessLiving with terminal illness Step 3: Comfort Care "See and treat patients as people, don't reduce them to a disease."– Dr Kate Granger Whether or not there’s a medical solution to make your life better, even if you can’t speak for yourself, your BestEndings Advance Directives can still include comfort care (also called Palliative Care). Comfort is important to me. If I can’t speak for myself, I want to be as free of suffering as possible. I direct the following comfort measures: (check all that apply) Pain medicationPain medication, even if it hastens my deathRelieve shortness of breathClear my airwaysRelieve agitation (feeling uncomfortable in my own skin)Relieve constipationRelieve discomfort from infections Mouth care (dry mouth, mouth sores, flossing)Skin care (bed sores, dry skin)Position for comfortSplint for comfortPalliative chemotherapy (for comfort, not cure)Palliative radiation (for comfort, not cure)Palliative surgery (for comfort, not cure)Complementary health care providers, for example Social Worker, Personal Support, Complementary Medicine (massage acupuncture), Spiritual CareOther personal requestsLife’s small pleasures Other Requests Small Pleasures Step 4: Quality of Life Any intervention or procedure may affect the quality of life you had before. Consider your quality of life now and the things that are important to you. If you cannot speak for yourself, the instructions you leave with loved ones about medical interventions and treatments may depend on: your overall health your family health history how long the intervention will be required possible side effects or complications from the intervention how long it may take to recover how your quality of life will be affected when you recover You can also direct that you want to let nature take its course –Allow Natural Death (AND) – while ensuring you are made comfortable. Considering quality of life, I consent to interventions or treatment if, when I recover, I can live independently YesNo I consent to interventions or treatment if, when I recover, I can eat and drink on my own YesNo I consent to interventions or treatment if, when I recover, I can go to the toilet by myself YesNo I consent to interventions or treatment if, when I recover, my brain will function as before procedure YesNo I consent to interventions or treatment if, when I recover, I need help to eat and drink YesNo I consent to interventions or treatment if, when I recover, I need help going to the toilet YesNo I consent to interventions or treatment if, when I recover, my quality of life is severely affected and I will need someone to take care of me YesNo Recovery time How long it takes to recover may be something you wish to consider. Recovery time after treatments can vary. I consent to interventions or treatments if recovery is expected to be 1 to 3 months3 to 6 months6 to 12 monthsany period of time I do NOT consent to any Heroic Measures, Proceedures or Treatments. My wish is to let nature take its course - Allow Natural Death (AND) - while ensuring my comfort. Step 5: You're halfway there! You’ve answered 50% of the questionnaire. Time to pause for thought. Here are a couple of things to keep in mind about the realities and complications of life’s end. Unlike past generations, most people have not seen someone dying. We are not familiar with the process or stages of dying. The reality can be scary and upsetting Often the expectation is that modern medicine can offer a solution to everything. Medical professionals are sometimes solely focused on saving life at all costs. For many health professionals saving lives is the very reason they got into the business. Comfort and peace of mind can be downplayed or considered less important than trying for a cure or extending life. It may fall to you or your loved ones to make decisions about when life is worth prolonging. Decisions about when to try to keep on keeping on can be difficult and heart-rending. "When you're walking through hell, keep on walking" - Winston Churchill Step 6: Revive me or Do Not Revive Me (DNR) For some, saving or prolonging life is what's most important. For others, quality of life is what's most important. It can be hard for people (including family and friends) to accept your choice. That's why it is so important to share your wishes with your decision-maker(s) and everyone who matters to you. You can direct: Do Not Revive by Cardio Pulmonary Resuscitation (CPR); do not connect to a Breathing Machine. Do Not Revive me (DNR): I have considered the options, and my decision is to direct letting nature take its course – Allow Natural Death (AND) – while ensuring my comfort. Yes DO revive me: if my heart stops, I consent to being revived by CPR (cardio-pulmonary resuscitation). Revive me: I agree to CPR (cardio-pulmonary resuscitation) I understand that there’s a good chance CPR will leave me bruised and possibly with broken ribsDo Not Revive me (DNR) If I stop breathing, I consent to a ventilator (breathing machine) tube down my throat and if necessary tracheostomy (hole in my neck) YesNo Step 7: Life-prolonging medical Interventions Along with CPR to restart your heart, and Breathing Machines when you're unable to breath on your own, there may be other life-prolonging interventions to consider, if you become too ill or injured to speak for yourself. One of the hardest decisions may be whether or not to supplement eating and drinking if you are unable to eat and drink on your own. Consider if you would consent to a feeding tube - whether in your nose, or stomach. If you want neither, you can direct that you want to voluntarily stop eating and drinking (VSED) To prolong my life, if I am unable to eat or drink, I consent to a feeding tube in the nose (NG) YesNo To prolong my life, if I am unable to eat or drink, I consent to a feeding tube in the stomach (PEG) YesNo I do NOT want to prolong my life using feeding tubes; I want the option to voluntarily stop eating and drinking (VSED) YesNo While not every decision can be foreseen or planned, you can direct that your wish is to save and prolong your life. I DO want my life saved and prolonged even if I am in a permanent vegetative state YesNo I DO want my life saved and prolonged even if I am brain dead YesNo I DO want my life saved and prolonged even if I won’t be able to live as before because my brain and abilities will be significantly damaged, and I am a burden on others YesNo I consent to Heroic Measures: I have considered my options, and I want my life saved and prolonged, while ensuring I am comfortable. Yes Step 8: Dementia or other loss of Brain function Dementia (Alzheimer’s, Lewey body and Vascular Dementia ) over time, will likely rob you of your mental abilities Should you have a Stroke, or be diagnosed with a disease such as Parkinson’s you may not be able to speak for yourself in the event of a medical decision. A brain injury or accident can also leave your brain damaged. If you are not competent to speak for yourself consider if you would like medical procedures or interventions to prolong your life. If your wish is not to prolong your life, but rather to let nature take its course, your direction is to Allow Natural Death (AND) while ensuring your comfort. I have considered the options,and my wish is to let nature take its course – Allow Natural Death (AND) – while ensuring comfort YesNo If you have already been diagnosed with Dementia (Alzheimer's, Lewy Body or Vascular Dementia) and know you likely will become incompetent to speak for yourself, consider if you would want to be revived if your heart stops or you stop breathing. As I've been diagnosed with Dementia and know I likely will become incompetent to speak for myself, I direct the following if my heart stops or I stop breathing: Revive me even if I no longer recognize my loved ones ReviveDo Not Revive Revive me even if I can no longer eat or drink by myself ReviveDo Not Revive Revive me even if I can no longer control my bladder (pee) or bowel (poop) movements ReviveDo Not Revive Revive me even if I've become disoriented and wander ReviveDo Not Revive Revive me even if I am often violent or disruptive ReviveDo Not Revive If you stop breathing do you want these heroic interventions to save or prolong your life? If I can't breathe on my own, I consent to Mechanical ventilation (breathing machine) YesNo If necessary, I consent to a Traechostomy (breathing tube inserted via hole in your neck) YesNo If your condition or illness progresses to the point where you can’t eat or drink on your own, consider if you would you want nutrition via feeding tubes to prolong your life. If I can't eat or drink on my own, I consent to a Feeding tube in the nose (NG) YesNo If I can't eat or drink on my own, I consent to a Feeding tube in my stomach (PEG) YesNo If you can't speak for yourself, consider if you would like these common life-prolonging interventions and treatments: To prolong my life, I consent to Dialysis YesNo To prolong my life I consent to antibiotics for infections (eg bladder,chest) YesNo Along with any treatment, proceedure or interventions, please ensure my comfort YesNo Step 9: Evaluation Before the last step, please help us make this process better. Your evaluation and input is very much valued! BestEndings Advance Directives step-by-step form was easy to use YesNoSomewhat BestEndings Advance Directives was helpful: 7 being the most helpful 7654321 Information on BestEndings Advance Directives was: HelpfulSomewhat helpfulMissing the following: Please describe: I would like more information on: Long Term CareHome CareFuneral PlanningEstate PlanningLegacy Planning Step 10: Last step. Confirm you're of sound mind Way to go. You made to the end. Now you just have to confirm you’re of sound mind. Easy, right? Date I am competent * I am able to make my own decisions and am not being forced or influenced.I am a competent adult who understands and accepts the consequences of my decisions.As my health changes, my options and decisions may change know that while I’m of sound mind, I can change these decisions whenever I wantI can’t plan for or consider decisions for every possible health situation, so I will explain what’s important to me for living Thank you for completing your BestEndings Advance Directives. If your health changes or you learn more about your end-of-life journey, you can always complete a new BestEndings Advance Directives. where to send your BestEndings Advance Directives Invite others to create their own BestEndings Advance Directives. Add emails to share your BestEndings Advance Directives email address email address email address