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    Advance Directive Worksheet

    A starter worksheet to help you think through end-of-life wishes. Talk it over with family and your doctor — and finalize with your state's legal advance directive form.

    Your healthcare proxy (the person who decides if you cannot):

    If your heart stops, do you want CPR (chest compressions and defibrillation)?

    If you cannot breathe on your own, do you want a breathing tube and ventilator?

    If you cannot eat, do you want a feeding tube?

    If you have a serious infection, do you want antibiotics?

    When the time comes, where do you want to receive end-of-life care?

    Do you want to donate organs and tissues?

    My Advance Directive Wishes

    Worksheet — not a legal document. Use this to guide a conversation, then complete the legal form for your state (caringinfo.org has free templates).