STATEMENT OF MY WISHES

1. My proxy. I name [name, relationship, phone] as my health-care agent, and [name, phone] as my alternate.

2. The life I'd want to return to. I would want treatment that is likely to return me to a life in which I can [recognize the people I love / speak with them / live outside a hospital or nursing facility / other, in my words].

3. A trial first. If it's uncertain whether treatment will return me to that life, I want it tried for [a number of days or weeks, or "as long as my doctors think a fair trial takes"], then reviewed with my proxy.

4. When it's unlikely. If my doctors believe it is unlikely I will return to that life, I do not want [resuscitation / a breathing machine / dialysis / artificial nutrition / hospital admission], and I want care focused on comfort, with palliative care or hospice, [at home / wherever I am].

5. Comfort. I want my pain and distress treated fully, even if the treatment may shorten my life.

6. What matters to me. [People to be with me. Music, faith, place. Anything I'd want to avoid.]

7. For my proxy. When this document doesn't answer a question, decide as you believe I would, and don't carry the decision as your own.