Client Directives Worksheet

The first choice is basically the "right to die if it will not do any good to keep me alive in a vegetative state" language, the second choice is the "prolong my life to greatest extent regardless of any other factors (including cost)" language, or you may enter your own custom language. Please let us know if you have any questions about this.

I am creating this document because I want my health care agents, medical providers, caregivers, family members and other loved ones to know and honor my wishes regarding assisted oral feeding of food and fluids if I am in an advanced stage of Alzheimer’s* or another incurable, advanced dementing disease and: (1) I am unable to make informed decisions about my health care; and, (2) I am unable to feed myself. *By “advanced stage of Alzheimer’s” I mean stage 6 or 7 (moderate to severe) of the Functional Assessment Staging Tool (“FAST”) which includes severe cognitive decline and the need for extensive assistance for most activities of daily living including toileting and eating. Why I Am Documenting My Instructions Concerning Oral Feedings? Under the conditions that may be imposed upon me by advanced dementia, including my inability to communicate comprehensively with loved ones or care givers, and my physical dependence on others for all aspects of bodily care, continuing life would have no value for me. In those conditions, I would want to die peacefully and as quickly as legally possible to avoid a drawn-out, prolonged dying that would involve unnecessary suffering for me and for those I love. This Advance Directive is intended to supplement any instruction I may have given in a health care proxy, living Will or other document.