My Strongly Held Beliefs

Many people have special personal or spiritual beliefs that they want to have respected in decisions about life-sustaining treatments. Do 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 do this, VA will treat the worksheet as part of your directive. 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.

  • My Beliefs
    Yes
    No
    Not sure
    Explanations of my beliefs
  • I should always be given food and fluids to prolong my life, even if it means I would need surgery to place a tube in my stomach.
  • I want to have my pain controlled, even if a side effect of the pain medication is that I can’t think clearly.
  • My spokesperson should consider my religious and spiritual views when making health care decisions on my behalf.
  • In addition to my interests, my spokesperson should consider his or her own interests and the interests of my family when making health care decisions on mybehalf.
  • My spokesperson should consider my views about the financial impact of treatment on my loved ones when making health care decisions on my behalf.
  • My spokesperson should follow my advance directive as closely as possible, even if he or she doesn’t think that it’s in my best interests.
  • Other
  • Other
  • Other
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