Imagining Different Situations

As you fill in this worksheet, remember that in each situation you’ve lost the ability to make your own health care decisions.

If I am unconscious, in a coma, or in a vegetative state and there is little or no chance of recovery
If I have permanent, severe brain damage that makes me unable to recognize my family or friends (for example, severe dementia)...
If I have a permanent condition where other people must help me with my daily needs (for example, eating, bathing, toileting)...
If I need to use a breathing machine and be in bed for the rest of my life...
If I have pain or other severe symptoms that cause suffering and can’t be relieved...
If I have a condition that will make me die very soon, even with life-sustaining treatments...
Worksheet Complete!

Great job on finishing this worksheet, at this time you can either download the PDF of your worksheet or email it to yourself.

Next Steps...

This worksheet will help you let your doctors and loved ones know your wishes for mental health care if you have a serious mental health condition.

To include your preferences about the use of life-sustaining treatment in an advance directive.

For guidance about how to talk to your loved ones and health care providers abour your wishes