After you finish sorting the 48 illustrated cards, you can enter your decisions here

What is the purpose of completing this form?

To upload a permanent record of your decisions regarding whether you want "Treat & Feed" or you want "Natural Dying" for each of the 48 cards/items you considered. You can also write down additional directions or instructions.

Caring Advocates will use your "data" to create your personalized Natural Dying-Living Will. Your proxy/agent and your future physician can use this document to decide WHEN it is time for Natural Dying.

If you sorted "real" jumbo-sized flash cards, you probably have three stacks of cards. You can complete your WALLET CARD and refer to it as you upload your data since the table looks the same.

If you have made your decisions using "virtual" cards then you or perhaps the person who interviewed you may have written your choices on a "My Decisions Table." (Examples of "virtual" sorting include: using an e-book version, or viewing a PowerPoint presentation at a workshop or seminar, or on a laptop, digital photo-frame, or tablet. You may also have sorted at a distance using the APP, "InterviewByInternet.com,"

Use these Initials to memorialize your decisions:

TF = "Treat & Feed," which means "Try to keep me alive. This item is NOT for Natural Dying."

NDE = "Natural Dying, Enough" given the amount of suffering expected from this item by itself.

DL =  “Decide Later.” My proxy/agent has 100% “leeway” to decide contemporaneously, if conditions I placed in this category will become NDE or remain the default of TF based on whether the condition causes… severe suffering? Or moderate suffering but TF provides little or no benefit? Or moderate suffering but several current DL conditions combine to make suffering severe?

(For card/items that are NOT important to you or are not relevant, skip them by leaving the choice blank.)

When you are done, the table on this computer page in SurveyMonkey should look just like either your wallet card or the "My Decisions Table."

Instructions on how to enter your data (if needed):

Suppose the first card in the "YES: DL along with other items" stack has the number "4.3".

Go down the Column on the extreme left that begins with "1." (Note the period is AFTER the "1".)
Stop when you reach Row “4.”

Now move to the right until you are under the Column that has the name above of “.3”.
This is Box "4.3".
Click any where on this box and select “Yes (DL with other items)” from the drop down list.
You should now see a "Yes (DL with other items)" in box “4.3”

When you have entered all your choices, hold your wallet card or "My Decisions Table" near your computer to make sure the numbers in the two tables are the same.

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First Name

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MI

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Last Name

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You must enter the date you sorted the 48 illustrated cards.

Date

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Indicate whether these are your INITIAL, FINAL, or Updated Final set of decisions. Usually, people sort the cards a second time about a month after their first sorting (but this can be longer).

We recommend updating any time you have change your mind -- which you can always do as long as your mind is "sound" -- and also after about year, to prove that your decisions are consistent over time. Some people just diligently review their Natural Dying--Living Will one year later and then write either, "No changes" or "I made the following changes because...." Make sure you have your written statement witnessed by two qualified individuals or notarized, so it is legally valid.

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Type in your Unique Identifying (Serial) Number.
This is the number on the back cover your printed deck of cards, or the number that you obtained by purchasing a Natural Dying--Living Will from the www.CaringAdvocates.org web site, or by calling 1 800 64 PEACE (800 647 3223).

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To generate your "Natural Dying--Living Will":
Enter your decisions for the 48 symptoms, loss of functions, unwanted behaviors, and conflicts with lifelong values from the three stacks of illustrated cards, from the completed wallet card, or from the completed My Decisions Table.
Hints:
If you want to change an item, click on the arrow again.
If you want to leave out an item, skip it. (If you made a decision and then decide to leave the item out, click on the top, blank space.)

  .1 .2 .3 .4 .5 .6
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Suppose you reach a condition for which you now judge you would want “Natural Dying by itself,” but you can still feed yourself and it is UNSAFE for you to swallow regular food and fluid. (Example: your risk of aspiration pneumonia is high.)

Do you want to be OFFERED thickened food and fluids—by placing them in front of you within your reach?

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You can use the space below in a variety of ways.

You can write in additional items for "TF", "NDE", or "DL" if the 48 items did not cover all your end-of-life wishes.

You can write down your explanations of your choices, although this is best done by making a video of yourself. Caring Advocates can help you do this.
You can explain why you left certain items out.
You can give special instructions for specific items.

You can also request specific kinds of treatment; for example, "Palliative Sedation."
Recommended: Discuss this treatment with your physician based on what you decided for card/item 6.6. This will determine IF your physician is willing to provide this treatment--for ANY kind of suffering (including "existential suffering"). Also discuss the variant called "Respite Sedation." This may allow you to wake up after a few days of total rest. Then you can see if you can handle your pain and continue treatment to enjoy more conscious living. Sometimes it is easier to find a physician who is willing to agree to Palliative Sedation if you also agree to be awakened after a few days. That is because the physician has the clear intent to reduce your suffering ONLY, not to hasten your dying.

Recommended: You and your physician sign the form provided by Caring Advocates: "Consent to Obtain Relief from Unbearable Suffering." Signing will indicate that you gave your informed consent and that your physician agreed to provide this treatment if needed.

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Indicate which “My Choice Card” you selected, to indicate how strongly you want your future decision-makers to follow your current preferences for treatment options.

Based on indicating your choices of TF, NDE, and DL for the items above, the day may come when you would want Natural Dying. By then you may be too ill to tell others how strictly you want them to follow your instructions.

So be clear now: "If I depend on others to feed and drink, I want NO tube feeding and NO high-tech medical treatment to try to keep me alive, AND I want one of these 4 choices: ..."

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Please explain the reasons why you chose A, B, C, or D, in your own words, below. (If you wish, you can refer to the commonly used reasons by others, in the Natural Dying Agreement.)

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There may be certain items for which you feel you cannot predict NOW what you would want in the FUTURE (that is, "Natural Dying" or "Treat & Feed"). You might feel this decision will depend on factors that will become clear only at that future time or that you might change your mind, but then... you will not have the ability to make such decisions. For example, some Advance Care Planners put card/item 8.6 in this category--even though for all the other items, they are sure they want their future physician to strictly follow the decisions they made now, themselves. You do not have to enter any card/items in the space below. You can just select "DL" for these cards. But if you want to highlight an item as an exception to your "My Choice Card A, or C, or D" so that your proxy/agent will make the decision in the future, type in the number of those cards/items below:

It is important to emphasize that food and fluid will NEVER be withheld from you. ONLY the assistance of another person's hand to put food and fluid into your mouth. Food and fluid will continue to be OFFERED by being PLACED in front of you for AS LONG AS YOU ARE AWAKE -- unless you state otherwise below by indicating HOW LONG you want them to be offered.

Write in this number of days in the space below.
(If you do not indicate a choice, then food and fluid will always be offered for as long as you are awake.)
(If you indicate "0" days, it means you NEVER want food or fluid to be placed in front of you.)

You may wish to discuss this choice with your physician and others.

Note: Some facilities feel obligated to OFFER you food and fluid, but they should still honor your Constitutional right to avoid bodily intrusion by forced, unwanted feeding. In the event of conflict, ask if your state law requires an objecting institution or physician to make a reasonable attempt to transfer you to another institution or physician who WILL honor your wishes--if they object to just "OFFERING" by placing food and fluid in front of you.

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Enter Number of Days you want the OFFER of food and fluid by placing them in front of you:

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(Note: Your street address is optional, but your e-mail address is necessary
so we can send you the completed survey and the Signature Page.
If you do not want to give us your real name, you can enter an alias.)

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Please enter your date of birth in the format MM/DD/YYYY.

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If you prefer us to FAX back your Living Will,
enter your FAX phone number below.

Note: You can change any decision any time, as long as your mind is "sound"; that is, you possess decisional capacity to make end-of-life treatment decisions.

If this is your second sorting/deciding, and you contact us within three days by e-mail or mail, we can change your Natural Dying--Living Will before we print and send it to you.

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In addition to providing service to individuals to help them arrive at prudent choices after informing them adequately, Caring Advocates strives to improve how medicine is practiced on a large scale. We want to learn what informed people will decide regarding their end of life treatment preferences.

Someday, we hope to have accumulated enough data to publish a report that respects the individual identity of all, while it provides needed information. For example the results may be used by surrogate decision-makers asked to make decisions for a loved one who did not indicate his or her wishes in advance. It could help making decisions based on the "Best Interest" ethical standard, which depends on knowing what perhaps the overwhelming majority of people would decide if they were in a similar condition with a similar prognosis. Caring Advocates promises anonymity so that information that could identify you will not be used. Still, you can still opt out by indicating this is your choice, below. Note: If you leave this question blank, we will assume you consent to using your responses anonymously:

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