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Thinking about what matters most in your life and sharing your hopes and fears will give you more control over the care you receive in the future. It will also help your loved ones to make decisions for you if you can’t make them at some point down the road.


This is the beginning of an ongoing discussion, however, we believe that individuals who think about what is important to them often feel more control of their situation, feel less anxious and reach a sense of peace.

To speak of sorrow works upon it, Moves it from its crouched place, barring the way to and from the soul’s hall
- Denise Levertov

Would you feel comfortable taking a few minutes to document your goals and wishes?


NOTE: If you exit this section of the website before completing and downloading the questionnaire, your answers will NOT be saved.

1 of 10

What is your understanding now of where you are with your illness?

2 of 10

What would you like to know about your illness and what lies ahead?

3 of 10

What type of information would help you make decisions about your future?

4 of 10

What is most important for you to have a good quality of life? What abilities or functions are so critical to your life that you can’t imagine living without?

5 of 10

If your health situation worsens, what are your most important goals?

6 of 10

What are your biggest fears and worries about the future of your illness?

7 of 10

What types of medical care do you NOT want?

8 of 10

Who looks at the world through your eyes? Who would you trust to make your medical decisions?

9 of 10

If you become sicker, how much are you willing to go through for the possibility of gaining more time? Do you prioritize more time or quality of life?

10 of 10

How much does your family know about your priorities and wishes?

Your answers

1

What is your understanding now of where you are with your illness?

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2

What would you like to know about your illness and what lies ahead?

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3

What type of information would help you make decisions about your future?

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4

What is most important for you to have a good quality of life? What abilities or functions are so critical to your life that you can’t imagine living without?

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5

If your health situation worsens, what are your most important goals?

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6

What are your biggest fears and worries about the future of your illness?

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7

What types of medical care do you NOT want?

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8

Who looks at the world through your eyes? Who would you trust to make your medical decisions?

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9

If you become sicker, how much are you willing to go through for the possibility of gaining more time? Do you prioritize more time or quality of life?

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10

How much does your family know about your priorities and wishes?

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Would you like to receive a copy of your reflections to have and share with your loved ones and your doctor?


Who looks at the world through your eyes? Which individual would you trust to make your medical decisions or be your power of attorney?