Questions to Think About
Most people who get COVID-19 get
better on their own. However, people
who are older or have other health
problems, like the ones listed on
the first page, can get very sick and
may not survive.
The treatments used to try to help
people live, such as breathing
machines and intensive care,
are not guaranteed to work.
You can make some decisions about
your health care now in case you
become very sick and are unable to
speak for yourself. (See the box at
the right.)
If you need more information, go to:
Allina Health: allinahealth.org/acp
Respecting Choices
®
:
respectingchoices.org
Honoring Choices:
honoringchoices.org
Minnesota Medical Association:
mnmed.org/polst.
This document does not replace
your current health care directive
or POLST form.
If this form contains information
that is different from your current
document, including your health care
agent, please complete a new one.
You can fill out a new health care
directive from allinahealth.org/acp.
Contact your health care provider
if you need to update your POLST.
This document can only be used until Dec. 31, 2020.
THIS FACT SHEET DOES NOT REPLACE MEDICAL OR PROFESSIONAL ADVICE; IT IS ONLY A GUIDE.
gen-ah-79186 (6/20)
© 2020 ALLINA HEALTH SYSTEM. TM – A TRADEMARK OF ALLINA HEALTH SYSTEM
OTHER TRADEMARKS USED ARE OWNED BY THEIR RESPECTIVE OWNERS
1. This material has been modified by us. The original content can be found at https://portal.ariadnelabs.org and is licensed by Ariadne Labs under the Creative
Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Ariadne Labs licenses the original content as-is and as-available, and makes no
representations or warranties of any kind concerning the original content or concerning this material, which Ariadne Labs has not reviewed or endorsed.
2. Materials developed by Respecting Choices®. ©Copyright 2019-2020 GLMF, Inc. All rights reserved.
What would be most important for your health care
providers or loved ones to know if you became very sick
and couldn’t speak for yourself?
___________________________________________________
___________________________________________________
___________________________________________________
Choose someone you trust to make decisions for you on
your behalf. This person acts as your health care agent.
Have you chosen a person who would do this for you?
If not, who could do this for you?
___________________________________________________
Some people decide to avoid treatments like breathing
machines or CPR if they may not help or may cause
suffering. Have you thought about your priorities for
medical care if you were to become very sick? Examples:
live as long as possible, even if that means being in
the hospital to receive all the care my doctors think
will help. I may need to rely on machines to stay alive.
live longer if I can keep the quality of life and comfort
I want. I may need to go to the hospital, stop any
treatments that do not work or make me feel worse,
or allow a natural death if my heart stops beating or
I stop breathing.
live the rest of my life focusing on my comfort and
quality of life. I want to avoid the hospital and allow
a natural death if my heart stops beating or I stop
breathing.
What worries you when you think about getting sick
with COVID-19?
___________________________________________________
___________________________________________________
___________________________________________________
