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5.1 A "Will to Live" Sample Template

Participants in the focus groups and mail-out surveys also indicated what they saw as key points to be included in a “Will To Live” Template. Additionally, one member of the disability community who had already created her own “will to live” suggested we draw on work done by Nancy Dubler and David Nimmons.²⁷ Some of the questions drawn up by these two American authors have helped others articulate their choices in life-and-death decisions.

Prior to developing a “Will to Live,” Dubler and Nimmons suggest gathering information about the sorts of decisions that might be faced²⁸. This includes having a discussion with your physician regarding the following:

	What kinds of possible health problems would your physician see as emerging for you in the future?
	What paths would your particular medical condition take that could impair your ability to participate in decisions about your care? Is this likely?
	What further medical information do you need?
	How does your physician feel about honouring your specific instructions?
	How do your wishes get communicated to the hospital if you are hospitalized and your doctor is not present?
	Does your physician feel comfortable playing the role of an advocate for your wishes?

One suggestion Dubler and Nimmons put forward is pre-recording your wishes for medical treatment, and reiterating your instructions to your proxy on video tape.²⁹

The following pages contain a sample of one possibility for a ‘Will to Live.”

WILL TO LIVE

PERTINENT INFORMATION

Name:
Address:
Telephone:
Doctor:
Manitoba Health #:
Contact in Case of Emergency:
Patient Proxy in Case of Inability to Communicate:
Physician:
Date:

If someone assisted you in completing a Will to Live, please fill in her/his name, address and relationship to you.

Name:
Address:
Relationship:

Details of Medical Information, including medications and any physical conditions, allergies, etc.³⁰

LEGAL DOCUMENTS

Please list in this category the existence and location of any living wills, power of attorney, and organ donation designations you might have.

Also, name your proxy, and any information that could help in locating that person or persons.

QUALITY OF LIFE STATEMENTS

A)	What is your overall attitude towards life? Are you happy to be alive? Do you feel that life is worth living?
B)	How satisfied are you with what you have achieved in your life?
C)	What goals do you have for your future?
D)	Does living with disabilities affect the level of satisfaction you have with life? (This could include how you describe your current health status, your ability to function, how well you’re able to achieve what you consider the basic necessities of life, etc.)
E)	Describe what you think is critical to achieving your quality of life: (This could include how important independence and self-sufficiency are to you; and how the experience of decreased physical &/or mental ability might affect your attitude towards your quality of life.)
F)	Describe what is important to you while undergoing medical care. (This could include what you consider appropriate in order to be treated with dignity; and, what you would want your relationship to social workers, care givers, nurses, therapists to include.)
G)	Describe what you need to protect your rights as a patient: (This could include communication concerns, the right to language translation or sign language interpretation, alternatives to print materials, and other disability-related accommodations required.)

EXPECTATIONS REGARDING MEDICAL PROCEDURES & TREATMENTS

A)	Describe what you want to have happen in critical medical circumstances (this could include a list of medical particulars regarding the obtaining or stoppage of treatment, and instructions stating that every treatment and care be maintained unless specifically requested otherwise):
B)	A Statement of Agreement Between You & Your Doctor:
C)	Instructions For Your Patient Proxy:
D)	Instructions in the Event Your Patient Proxy Cannot Be Present: (This could include the designation of an alternate proxy, and instructions that if there is any question of a patient being in a fit mental state, all care should be taken until the proxy or alternate arrives to make a decision on your behalf.)

ATTITUDES TOWARDS DEATH AND DYING

A)	What will be important to you when you are dying? (This could include what you want in terms of physical comfort, who you would want present, and where you would want to be.)
B)	How do you feel about the use of life-sustaining treatment measures in the face of terminal illness? What do you consider to be “terminal illness”?
C)	Are there religious considerations important to you that should be considered when you are dying?
D)	Any additional comments about your wishes concerning death and dying?

WITNESS AND SIGNATURE

Witness to this Document:

(It is important that the witness to this document and the proxy named in the document are two different persons.)

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27	Nancy Dubler, Esq. & David Nimmons. Ethics on Call: A Medical Ethicist Shows How to Take Charge of Life-and-Death Choices. NY: Harmony Books. 1992.
28	Ibid. 343 ff.
29	Ibid. 364.
30	It is very important to note that this report has not included questions that name specific medical conditions. The scope of this project did not allow for adequate research to include that kind of information. It would be incumbent on any further development of a "Will to Live" template to have more specific medical and legal details.

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The Will To Live Template Project - Contents