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Dear%Doctor,%
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My%Doctor's%name!!
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RE:%What%matters%most%to%me%at%the%end%of%my%life%
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"!#$%&!'&&(!)&$*+(,!$(*!-#+(.+(,!$'/0-!&(*1/213+2&!+440&4!3$-&356!"!)&$3+7&!#/8!
+9:/)-$(-!+-!+4!-#$-!"!;/990(+;$-&!95!8+4#&4!-/!5/0!$(*!95!2$9+356!"!.(/8!-#$-!5/0!
$)&!%&)5!'0456!
</0!9$5!2+(*!+-!$8.8$)*!-/!-$3.!-/!9&!$'/0-!95!&(*1/213+2&!8+4#&4!/)!5/0!9$5!2&&3!
-#$-!+-!+4!-//!&$)35!2/)!9&!-/!#$%&!-#+4!;/(%&)4$-+/(6!=/!"!$9!8)+-+(,!-#+4!3&--&)!-/!
;3$)+25!8#$-!9$--&)4!9/4-!-/!9&6!
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My%name!!
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What%Matters%Most%to%Me%
>?$9:3&4@!A&+(,!$-!#/9&B!*/+(,!,$)*&(+(,B!,/+(,!-/!;#0);#B!:3$5+(,!8+-#!95!
,)$(*;#+3*)&(!
!
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My%important%future%life%milestones:%
>?$9:3&4@!95!CD-#!8&**+(,!$((+%&)4$)5B!95!,)$(*4/(!#+,#!4;#//3!,)$*0$-+/(B!'+)-#!
/2!95!,)$(**$0,#-&)!
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!
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Here%is%how%we%prefer%to%handle%bad%news%in%my%family%
>?$9:3&4@!E&!-$3.!/:&(35!$'/0-!+-B!8&!4#+&3*!-#&!;#+3*)&(!2)/9!+-B!8&!*/!(/-!3+.&!-/!
-$3.!$'/0-!+-B!8&!*/!(/-!-&33!-#&!:$-+&(-!
!
!
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Here%is%how%we%make%medical%decisions%in%our%family%%%%%%%%%%%%%%%%%
>?$9:3&4@!"!9$.&!-#&!*&;+4+/(!954&32B!95!&(-+)&!2$9+35!#$4!-/!$,)&&!/(!9$F/)!
*&;+4+/(4!$'/0-!9&B!95!*$0,#-&)!8#/!+4!$!(0)4&!9$.&4!-#&!*&;+4+/(4!&-;6!
!
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©VJ Periyakoil, MD 2015
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Here%is%who%I%want%making%medical%decisions%for%me%when%I%am%not%able%to%
make%my%own%decisions%
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C6!
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G6!
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H6!!
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What%I%DO%NOT%want%at%the%end%of%my%life%
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"!*/!(/-!8$(-!-/!'&!/(!$!')&$-#+(,!9$;#+(&!
"!*/!(/-!8$(-!$)-+2+;+$3!3+I0+*!2&&*+(,!
"!*/!(/-!8$(-!*+$354+4!
"!*/!(/-!8$(-!-/!4:&(*!95!3$4-!*$54!+(!$!#/4:+-$3!
"!*/!(/-!8$(-!-/!*+&!$-!#/9&!
J-#&)!!
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What%I%DO%WANT%at%the%end%of%life%
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"!8$(-!-/!'&!:$+(!2)&&!
"!8$(-!-/!4:&(*!95!-#&!3$4-!*$54!+(!-#&!#/4:+-$3!
"!8$(-!5/0!-/!#&3:!9&!*+&!,&(-35!$(*!($-0)$335!
"!8$(-!-/!*+&!$-!#/9&!
"!8$(-!#/4:+;&!;$)&!
J-#&)!
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If%my%pain%and%distress%are%difficult%to%control,%please%sedate%me%%(make%with%
sleep%with%sleep%medicines)%even%if%this%means%that%I%may%die%sooner%
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<&4!
K/!
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©VJ Periyakoil, MD 2015
What%to%do%when%my%family%wants%you%to%do%something%different%than%what%I%
want%for%myself?%
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I!am!asking!you!to!show!them!this!letter!and!guide!my!family!to!follow!my!!!!!!
wishes.!
I!want!you!to!override!my!wishes!as!my!family!knows!best.!
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Other%information%you%want%to%convey%
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Please!scan!this!letter!into!my!medical!records!in!a!place!where!your!colleagues!can!
read!this!and!be!guided!by!it.!I!thank!you!doctor!for!listening!to!me!now!and!for!the!
future!work!you!are!about!to!do!guided!by!what!matters!most!to!me.!!
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Your!grateful!patient,!!
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_____________________________________________________________________!
©VJ Periyakoil, MD 2015