My Last Days

Many people feel strongly about what would be important to them at the very end of their lives. Some people want to have certain things happen. Others want to make sure to avoid things that they fear or don’t like.

What are some of the things that are most important to you? Use this worksheet to discuss your choices with your spokesperson, loved ones, and health care providers.

You may attach a copy of this optional worksheet to your VA Advance Directive if you choose to complete one. Be sure to initial each page. If you give the worksheet to your health care provider, it will become part of your medical record, and will be protected like your other medical information. If you do this, VA will treat the worksheet as part of your directive.

Medical Situation Not important Moderately Important Very Important Extremely Important
Avoiding pain and suffering.
Being alert.
Being around my family and close friends.
Being able to feel someone next to me or touching me.
Being able to tell my life story and leave good memories for others.
Having religious or spiritual advisors at my side when I die.
Reconciling differences and saying "good-bye" to my family and friends.
Being at home when I die.
Being in a hospital when I die.
Staying alive long enough for my family to get to my bedside before I die, even if I'm unconscious.
More information:
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.