Are Some Conditions Worse Than Death?

Are Some Conditions Worse Than Death?

Name & Date________________________________
This worksheet helps you to think about situations in which you would not want medical treatments intended to keep you alive. These days, many treatments can keep people alive even if there is no chance that the treatment will reverse or improve their condition. Ask yourself what you would want in the situations described below if the treatment would not reverse or improve your condition.
Directions: Circle the number from 1 to 5 that best indicates the strength and direction of your desire. If you wish, you can add additional thoughts on the Comment lines.

1. 1  -- Definitely want treatments that might keep you alive.
   
2. 2  -- Probably would want treatments that might keep you alive.
   
3. 3  -- Unsure of what you want.
   
4. 4  -- Probably would NOT want treatments that might keep you alive.
   
5. 5  -- Definitely do NOT want treatments that might keep you alive.
   

What If You . . .
a. No longer can recognize or interact with family or friends.

Definitely Want Treatment

Definitely
Do Not Want Treatment

1 2 Comment__________________________________________________________________

2. No longer can think or talk clearly. 1 2 3 4 5 Comment__________________________________________________________________
   
3. No longer can respond to commands or requests. 1 2 3 4 5 Comment__________________________________________________________________
   
4. No longer can walk but get around in a wheel chair. 1 2 3 4 5 Comment__________________________________________________________________
   
5. No longer can get outside and must spend all
   day at home. 1 2 3 4 5
   Comment__________________________________________________________________
   
6. Are in severe untreatable pain most of the time. 1 2 3 4 5
   Comment__________________________________________________________________
   

ABA Commission on Law and Aging Tool 2 / Page 1

3

4

5

Tool #2

What If You . . .
g. Are in severe discomfort most of the time (such as nausea, diarrhea).

Definitely Want Treatment
1 2

3

4

Definitely
Do Not Want Treatment
5

Comment__________________________________________________________________

8. Are on a feeding tube to keep you alive. 1 2 3 4 5
   Comment__________________________________________________________________
   
9. Are on a kidney dialysis machine to keep you alive. 1 2 3 4 5
   Comment__________________________________________________________________
   
10. Are on a breathing machine to keep you alive. 1 2 3 4 5
    Comment__________________________________________________________________
    
11. Need someone to take care of you 24 hours a day. 1 2 3 4 5
    Comment__________________________________________________________________
    
12. No longer can control your bladder. 1 2 3 4 5
    Comment__________________________________________________________________
    
13. No longer can control your bowels. 1 2 3 4 5
    Comment__________________________________________________________________
    
14. Live in a nursing home permanently. 1 2 3 4 5
    Comment__________________________________________________________________
    

o.Other: 12345
Explain____________________________________________________________________

ABA Commission on Law and Aging Tool 2 / Page 2 
source 

Are Some Conditions Worse Than Death?

Name & Date________________________________
This worksheet helps you to think about situations in which you would not want medical treatments intended to keep you alive. These days, many treatments can keep people alive even if there is no chance that the treatment will reverse or improve their condition. Ask yourself what you would want in the situations described below if the treatment would not reverse or improve your condition.
Directions: Circle the number from 1 to 5 that best indicates the strength and direction of your desire. If you wish, you can add additional thoughts on the Comment lines.

1. 1  -- Definitely want treatments that might keep you alive.
   
2. 2  -- Probably would want treatments that might keep you alive.
   
3. 3  -- Unsure of what you want.
   
4. 4  -- Probably would NOT want treatments that might keep you alive.
   
5. 5  -- Definitely do NOT want treatments that might keep you alive.
   

What If You . . .
a. No longer can recognize or interact with family or friends.

Definitely Want Treatment

Definitely
Do Not Want Treatment

1 2 Comment__________________________________________________________________

2. No longer can think or talk clearly. 1 2 3 4 5 Comment__________________________________________________________________
   
3. No longer can respond to commands or requests. 1 2 3 4 5 Comment__________________________________________________________________
   
4. No longer can walk but get around in a wheel chair. 1 2 3 4 5 Comment__________________________________________________________________
   
5. No longer can get outside and must spend all
   day at home. 1 2 3 4 5
   Comment__________________________________________________________________
   
6. Are in severe untreatable pain most of the time. 1 2 3 4 5
   Comment__________________________________________________________________
   

ABA Commission on Law and Aging Tool 2 / Page 1

3

4

5

Tool #2

What If You . . .
g. Are in severe discomfort most of the time (such as nausea, diarrhea).

Definitely Want Treatment
1 2

3

4

Definitely
Do Not Want Treatment
5

Comment__________________________________________________________________

8. Are on a feeding tube to keep you alive. 1 2 3 4 5
   Comment__________________________________________________________________
   
9. Are on a kidney dialysis machine to keep you alive. 1 2 3 4 5
   Comment__________________________________________________________________
   
10. Are on a breathing machine to keep you alive. 1 2 3 4 5
    Comment__________________________________________________________________
    
11. Need someone to take care of you 24 hours a day. 1 2 3 4 5
    Comment__________________________________________________________________
    
12. No longer can control your bladder. 1 2 3 4 5
    Comment__________________________________________________________________
    
13. No longer can control your bowels. 1 2 3 4 5
    Comment__________________________________________________________________
    
14. Live in a nursing home permanently. 1 2 3 4 5
    Comment__________________________________________________________________
    

o.Other: 12345
Explain____________________________________________________________________

ABA Commission on Law and Aging Tool 2 / Page 2
americanbar.org/content/dam/aba/migrated/aging/toolkit/tool2.authcheckdam.pdf