Download in English. Other versions available on the Advanced Directive Resources page.
Advanced Directive Planning Sheet [ASL translation]
Your name:
Your address:
Your phone number:
Your email address:
Health Care Representative [ASL translation]
If you are unable to make or communicate your health care decisions, a health care representative (HCR) can help make those decisions for you. The questions below are designed to help you decide whether to appoint one or more HCR(s), who to choose, and the decisions they can make.
An HCR can:
- Say yes or no to any life support or medical treatment if you cannot do so yourself; and
- Decide what happens to your body after you die, such as organ donation, autopsy, and funeral plans.
Advanced Directive Effective Event [ASL translation]
When do you want your HCR to be appointed? (Please choose one.)
Immediately after you sign the form.
When a doctor or court decides you can't make decisions for yourself.
Effective on the following date:
Notes:
Decision-Making Standards for Health Care Representative(s) [ASL translation]
Do you want your HCR(s) to follow your wishes or have flexibility? (Choose one.)
No flexibility: My HCR(s) should follow my medical wishes as I have stated. My HCR cannot change my wishes, even if my doctors recommend it.
Some flexibility: My HCR(s) can make medical decisions that differ from my previously stated wishes if my doctor recommends it. However, my HCR(s) cannot alter these specific wishes (describe below) under any circumstances:
Total flexibility: My HCR(s) can make decisions that are different from my previously stated medical decisions if my doctors recommend it. (If your HCR does not know and cannot find out your specific wishes for a medical situation that comes up, then the HCR must act in your best interests. See IC 16-36-7-36.)
Notes:
Your Continuing Right to Act and Decide Personally [ASL translation]
How do you want to make medical decisions? (Choose one.)
I want to make medical decisions by myself with or without supporters.
I want to have a trusted person make medical decisions for me.
Please explain your choice.
Important Aspects of Your Life [ASL translation]
What people, activities, or things are most important to you? (Choose all that apply.)
Thinking about the people or things that are important to you can help you discover who in your life might be a good support. It can also help others know the value of these things in your life.
My family (name(s))
My friends (name(s))
My pet (type(s) and name(s))
My hobbies and interests
Working/volunteering
My home
My religion, spirituality, or faith
Something else
Notes:
Based on your current health, what would you like doctors to do if you have a life-threatening event? (Choose one.)
I want all medical care necessary for me to live as long as possible.
I would rather die than live with significant discomfort or permanent reliance on medical equipment.
My wishes are somewhere between the two choices above. (Please explain.)
Based on your current health, what do you consider a good quality of life? (Please explain.)
Based on your current health, what do you consider a poor quality of life? (Please explain.)
Which of the following choices would worsen your quality of life? (Choose all that apply.)
Being in a coma and unable to wake up or talk to family and friends.
Needing machines connected to my body to live.
Not being able to remember family, friends, or important events.
Needing to live in a hospital or nursing home.
Having constant or severe physical discomfort.
Not being able to eat or drink by mouth.
Not being able to move my limbs.
Not being able to communicate verbally.
Something else. (Please explain.)
Why did you choose as you did? Please list any other information you want your medical providers and/or HCR(s) to know:
Your Wishes and Preferences About Life-Prolonging Procedures [ASL translation]
If you were so sick or old that you were going to die soon, how would you like doctors to address a life-threatening event? (Choose one.)
I want all medical care necessary for me to live as long as possible.
I want to enjoy my remaining life without medical treatment.
I want to be comfortable and without pain but no life-prolonging medical treatment.
I want something specific depending on the circumstances. (Please explain.)
Your Health Care Representative(s) [ASL translation]
Who do you want to be your HCR(s)?
HCR 1
First and last name:
Phone number:
Email address:
Relationship:
State they live in:
HCR 2
First and last name:
Phone number:
Email address:
Relationship:
State they live in:
If you have more than one HCR, how should they make decisions? (Choose one.)
One HCR is the main decision maker and the second is a backup if the main HCR is unable or unavailable.
- Main HCR:
- Backup HCR:
My HCRs must agree with each other on each decision.
Either one can make a decision independently.
Notes:
End-of-Life Preferences [ASL translation]
If able to choose, where would you want to die? (Choose one.)
At home
In the hospital
Other (please explain)
What is more important to have around you when you are dying (e.g., food, music, pets, or people)? (Please explain.)
If you were very likely to die soon, which life support measures would you want?
All life support treatments that might help. I want treatment even if there is little hope of recovery or improvement.
Life support treatments that doctors think might help. I do not want to stay on life support if it is not working and there is little hope of improement.
I do not want any life support measures, even if I die.
I want the following (check all that apply):
Food and water by mouth.
Food and water through a feeding tube or transfusions.
A breathing machine that can be easily taken off.
A breathing machine that involves a tube inside my body.
Cardiopulmonary resuscitation (CPR)
Dialysis.
Other machine assistance.
Blood transfusions.
Antibiotics.
Medication to make me comfortable.
Why did you choose as you did? Please list any other information you want your medical providers and/or HCR(s) to know about your preferences.
Do you want to donate your organs or body parts? (Choose one.)
I want to donate any of my organs or body parts that can be used.
I do not want to donate my organs or body parts.
I want to donate only these specific organs and/or body parts:
Do you want an autopsy performed after your death? (Choose one.)
I want an autopsy.
I do not want an autopsy.
I only want an autopsy if there are questions about the cause of my death.
Do you have funeral or burial wishes?
I have the following religious or spiritual wishes:
I have the following funeral or burial wishes:
I am interested in donating my body to science:
If you have a particular organization you would like to donate your body to (such as an institution, school, hospital, or cause) please provide this information:
Name:
Address:
Phone number:
Email:
Notes:
This Advanced Directive Planning Sheet was funded by the Indianapolis Bar Foundation.
Version 3: Last updated 23.6.10