Living Wills and Advance Directives

This survey on living wills and advance directives is for seniors and their families - and anyone else who may be interested. It is being done for the Seniors Support website, http://seniors-support.com.

The information will be gathered and tabulated to give us an idea of what information may be lacking, if any, in terms of advance planning.

Thank you for taking the time to take this short survey and please do visit Seniors Support to see what the outcome is.

Marijke

1. Do you know what living wills or advance directives are?

Do you know what living wills or advance directives are? Yes, I do.

No, I don't.

I think I do.

2. Do you have a living will or advance directives?

Do you have a living will or advance directives? Yes, I have a living will or advance directives.

No, I don't have a living will or advance directives.

I do have a living will/advance directives but it needs to be reviewed.

I don't have a living will/advance directives but I should.

I've been meaning to have a living will/advance directive but haven't gotten around ot it yet.

I don't have a living will/advance directives and I don't plan on it.

Other (please specify)

3. If you do have a living will/advance directives did you (check all that are appropriate):

If you do have a living will/advance directives did you (check all that are appropriate): prepare it on your own?

research it on the Internet?

ask for help from a legal professional?

ask for advice from a medical professional?

store it with a legal professional?

store it at home?

advise friends or family about your wishes?

Not applicable, I don't have one

Other (please specify)

4. Have you ever discussed living wills with other people about if they have one or not?

Have you ever discussed living wills with other people about if they have one or not? Yes

Other (please specify)

5. Have you ever been involved in a situation where someone you cared about may have benefited from having a living will or advance directives?

Have you ever been involved in a situation where someone you cared about may have benefited from having a living will or advance directives? Yes

I don't know

Other (please specify)

6. How important do you think it is for someone to have a living will or advance directives?

How important do you think it is for someone to have a living will or advance directives? Extremely important

Very important

Important

Not very important

Not important at all

7. If you don't have a living will/advance directives, this is because (check all that are appropriate):

If you don't have a living will/advance directives, this is because (check all that are appropriate): I don't know what they are.

I don't think I need one.

I don't want one.

It's too costly.

I don't know how to go about doing it.

I don't know what is involved.

my family wouldn't pay attention anyway.

doctors and nurses won't take good care of me if I have one.

I don't know what I want to happen to me.

Not applicable because I have one.

Other

Other (please specify)

8. Please rate the importance of including the following issues in a living will or advance directive:

	Extremely important	Very important	Important	Not very important	Not important at all	N/A
Use of artificial means for life support (ex: ventilators)	Please rate the importance of including the following issues in a living will or advance directive: Use of artificial means for life support (ex: ventilators) Extremely important	Very important	Important	Not very important	Not important at all	N/A
Use of tube feeding for nourishment	Use of tube feeding for nourishment Extremely important	Very important	Important	Not very important	Not important at all	N/A
Performance of cardiopulmonary resuscitation (CPR) in case of cardiac arrest	Performance of cardiopulmonary resuscitation (CPR) in case of cardiac arrest Extremely important	Very important	Important	Not very important	Not important at all	N/A
Treatment for illness such as infections during end-of-life	Treatment for illness such as infections during end-of-life Extremely important	Very important	Important	Not very important	Not important at all	N/A
Use of intravenous fluids to maintain nutrition during end-of-life care.	Use of intravenous fluids to maintain nutrition during end-of-life care. Extremely important	Very important	Important	Not very important	Not important at all	N/A

Other (please specify)

9. What, if anything, would you like to learn about living wills and advance directives?

What, if anything, would you like to learn about living wills and advance directives?

10. Now that you have taken this survey, has this changed your thoughts about living wills/advance directives?

Now that you have taken this survey, has this changed your thoughts about living wills/advance directives? Yes

I'm not sure

Other (please specify)

1. Default Section

1. Do you know what living wills or advance directives are?

2. Do you have a living will or advance directives?

3. If you do have a living will/advance directives did you (check all that are appropriate):

4. Have you ever discussed living wills with other people about if they have one or not?

5. Have you ever been involved in a situation where someone you cared about may have benefited from having a living will or advance directives?

6. How important do you think it is for someone to have a living will or advance directives?

7. If you don't have a living will/advance directives, this is because (check all that are appropriate):

8. Please rate the importance of including the following issues in a living will or advance directive:

9. What, if anything, would you like to learn about living wills and advance directives?

10. Now that you have taken this survey, has this changed your thoughts about living wills/advance directives?