CareAhead Planner

Step 1: Personal Information

Full Name Date of Birth Address Email Address Preferred language

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List your medical conditions Medication allergies

No Yes

Please specify your allergies:

Step 2: Medical Understanding and Preferences

Who have you spoken to about your values and care preferences? How did the discussion go?

What do you understand about your current medical condition?

I have a good understanding of my health condition. I know I’m unwell, but I’m not sure what it means long-term. I’m not clear about my condition. I prefer not to know more details right now.

What is most important to you right now?

To live as long as possible, even if that means more medical treatment. To be comfortable, even if it may shorten my life. To be with family or loved ones. I'm not sure yet.

If your condition worsens, which approach do you prefer?

Full medical treatment, including resuscitation and ICU care. Limited treatment (e.g., no CPR, ICU, intubation but hospital care is okay). Comfort care only (focus on pain relief and symptom control).

What are your preferences regarding tube feeding?

I do not want tube feeding. I am open to a trial period, but not long-term. I am okay with long-term tube feeding if needed.

What are your preferences regarding dialysis if your kidneys fail?

I do not want dialysis. I am open to a trial period of dialysis. I am okay with long-term dialysis if it supports quality of life.

Where would you prefer to be cared for if your condition worsens?

At home In the hospital In a hospice I have no preference

Who should make decisions for you if you can’t?

I have appointed someone legally (e.g., LPA). I trust my family to decide. I want the medical team to decide.