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Consider using this checklist as a starting point for thinking about what you would want your designated health care agent to know if they need to act to make decisions on your behalf. This is an evolving conversation and you are encouraged to discuss this periodically with your agent, especially when your health or wishes change.

Helpful Information to Share with Your Health Care Agent

  • The list of who should be notified about your situation (include names, relationship, and contact information). This might include religious representatives and wishes related to prayer or services.
  • Medical history (where and when to obtain such history and where to find the agent’s authority to do so).
  • Allergies (including food and medications).
  • Contact information for primary care physician and any medical specialists, therapists for any therapies you are receiving or wish to receive, and other providers.
  • Information about health insurance, long-term care insurance, disability insurance (including account numbers, details of coverage, and phone numbers of providers).
  • Location of your power of attorney or other legal documents.

Topics to Consider and Possibly Discuss with Your Health Care Agent

  • Are there treatments you particularly want to receive or refuse? For example, would you want to receive treatments such as mechanical ventilation, antibiotics, or tube feeding for a certain length of time, but have them stopped if there were no improvement in your condition? Does it matter if the treatment is in an experimental phase?
  • Is there a stage where you do not want to receive any further treatment? What is the triggering point? Not being able to swallow food and water safely? Not being able to communicate? Not being able to recognize family and loved ones? Something else?
  • What are your views about artificial nutrition (meaning being fed food through a tube) and hydration (meaning being provided fluids through IV)? Keep in mind this is different from pain management.
  • Have you entered into a Do Not Resuscitate (“DNR”) with your doctor? If so, tell your agent. If not, discuss under what conditions you would want your agent to enter into a DNR with your doctor when you are unable to communicate your wishes.
  • Do you want to remain at home for as long as possible or would you prefer your agent to move you to an assisted living facility, nursing facility, hospice facility, or hospital?
    • If your agent needs to make a decision about your living arrangements because it becomes unsafe for you to stay at home or because you have expressed a preference to be moved, what is the determining factor? Where you can receive the best care? Where it is convenient for family? Should the facility have a religious or other affiliation? Or some other factor?
  • What are your priorities regarding the length of your life, the quality of your life, and the balance between the two?
  • Are there any types of service providers you would like to visit you (e.g., physical therapist, massage therapist, acupuncturist, an energy healer, manicurist, hair stylist)?
  • Do you prefer constant visitors (as allowed by hospital policy) or would you like breaks from visitors? Would you prefer only close family/friends? Are there people who should be prohibited from visiting you? If death is imminent, who would you like by your side? Or would you prefer to be alone? Are there things you would like visitors to do (e.g., read to you, hold your hand, sing to you, play particular music, etc.)?
  • Are there any particular objects you would like with you (e.g., photos, mementos, special clothes or blankets) if you are no longer in your home or during the dying process?
  • Do your wishes change about any of the above if you are suffering from dementia, bearing in mind that if you are suffering from dementia your agent may be making decisions for you for an extended period of time?
    • You may also want to discuss romantic relationships and the changes that they might undergo if you are suffering from dementia.
    • If you are suffering from dementia, it is likely that you will need to stop driving at some time. This decision may make you feel a loss of independence and autonomy or your loved ones to feel a sense of guilt. How should this be handled?