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Values History
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Values History

Why a Values History Form?

The Values History Form recognizes that medical decisions we make for ourselves are based on the beliefs, preferences and values that matter most to us: How do we feel about independence and control? About pain, illness, dying and death? What in life gives us pleasure? Sorrow? A discussion of these and other values can provide important information for those who might, in the future, have to make medical decisions for us when we are no longer able to do so.

Further, a discussion of the questions asked on the Values History Form can provide a solid basis for families, friends, physicians and others when making medical decisions. By talking about these issues ahead of time, family disagreements may be minimized. And when decisions do need to be made, the burden of responsibility may be lessened because others feel confident of your wishes.

How do I fill out the Values History Form?

The Values History Form asks a number of questions about issues such as: Your attitude toward your health; Your feelings about your health care providers; Your thoughts about independence and control; Personal Relationships; Your overall attitude toward life; Your attitude toward illness/dying/death; Your religious background and beliefs; Your living environment; Your attitude toward finances; Your wishes concerning your funeral. Simply answer the questions. The form also allows you to record both written and oral instructions you might already have prepared.

There are a number of ways in which you might begin to answer these questions. Perhaps you would like to write out some of your own thoughts before you talk with anyone else. Or you might ask family and friends to come together and talk about your -and their - responses to the questions.

Often simply making copies of the Values History Form available to others is enough to get people talking about a subject that, for many of us, is difficult and painful to consider. The most important thing to remember is that it is easier to talk about these issues BEFORE a medical crisis occurs. Feel free to add questions and comments of your own to those already provided.

What should I do with my completed Values History Form?

Make certain that all those who might be involved in future medical decisions made on your behalf are aware of your wishes: family, friends, physicians and other health care providers, your lawyer, your Pastor. If appropriate, provide written copies to these people. But remember that each of us continues to grow and change, and so the Values History Form should be discussed and updated fairly regularly, as preferences and values evolve. Consider attaching a copy of it to your Living Will , Durable Power of Attorney, or Advance Directive for Health Care, if you have one, or filing the Values History Form with your important medical papers.

Who should consider preparing a Values Form?

Everyone. While it has been customary to focus on older people, it is just as important that younger people discuss these issues and make their wishes known. Often some of the most difficult medical decisions must be made on behalf of these younger patients. If they had talked with families and friends, these decision makers could feel reassured they were following the patient's wishes.

What if I do not have a Living Will or Durable Power of Attorney for Health Care?

Whether you sign either of these is entirely up to you, and laws governing these vary from state to state.




For information and assistance, the following agencies might be of help:

Concern for Dying/Society for the Right to Die
250 West 57 Street, New York, NY 10107

This agency will provide legal information about Living Wills and Durable Powers of Attorney for Health Care, as applicable in your own state. Please write to them at the above address. Because of the recent large volume of requests, expect a 4-6 week turn- around time. If you have an emergency, you may telephone them, but they caution that it is very difficult to get through on the telephone.

American Association of Retired Persons
For a single, free copy of the Health Care Power of Attorney booklet, please send a postcard with your name and address to:

AARP Fulfillment (Stock No. D13895)
1909 K Street, N.W.
Washington, D.C. 20049

You might also contact your local Office of Senior Affairs, your State or Area Agency on Aging, agencies providing Legal Services for the Elderly, or your personal attorney.

We hope this Values History Form is of help to you, your families and friends. Many people have commented that it is important to reflect not so much on "How I want to die," but rather on "How I want to LIVE until I die."

Select the link below for the Values History Form and instructions for completing the form.

Values History Form