National Healthcare Decisions Day
Advance care planning worksheet
Thank you for beginning your advance care plan. By talking about your values, preferences and
beliefs, your loved ones and doctors will better understand what you want. Answer these questions
to get started. Bring this document with you when you receive care.
My name is___________________________________________
Who do you want to make health care decisions for you if you can’t speak for yourself? This person
will be your health care advocate. It may or may not be a family member. It should be someone
Knows you well
Is calm in a crisis
Understands how you would
make decisions
Can ask questions and advocate to
your doctors
Can communicate well with your family
I choose ____________________as my advocate. Relationship _______________________________
Phone number: ____________________________ Email: _________________________________
If that person is not able or available, my alternates are:
1st alternate name: ________________________ 2nd alternate name: _____________________
Relationship: ______________________________ Relationship: ___________________________
Phone number: ____________________________ Phone number: _________________________
Email: ____________________________________ Email: _________________________________
What brings me joy or meaning? For example, taking walks, being with family, learning new things,
being outside, gardening:
These are the things that bring me comfort when I’m sick. For example, listening to music, feeling
safe, connecting with family, staying warm:
What would be most important to you in this situation?
Would you want life-sustaining treatment in this situation, such as CPR or a ventilator?
When, if ever, should your advocate decide to stop life-sustaining treatment?
If I am nearing the end of my life, it will be important for me to have:
What I want the people around me to know before I die:
Now discuss this with:
Next steps:
Send this document to your doctor and ask for it to be added to your medical record.
Bring this document with you when you receive care.
Revisit your preferences as your life changes.
For a more formal document, download your state’s advance directive at
Your advocate
Your alternate advocates
Your doctors
Your family
Imagine if a sudden, serious event or illness leaves you unable to communicate.
There is a small chance that you will recover. Your advocate and medical team must
decide what treatments best fit with your values.
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