The purpose of this form is to assist you in thinking about and writing down what is important to you about your health. If you should at some time become unable to make health care decisions for yourself, your thoughts as expressed on this form may help 
others make a decision for you in accordance with what you would have chosen.

WHY A VALUES HISTORY FORM? 

The Values History Form recognizes that medical decisions we make for ourselves are based on those 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 such medical decisions. By talking about such issues ahead of time, family disagreements may be minimized. And when such decisions do need to be made, the burden of responsibility may be lessened because others feel confident of your wishes.

The first section of this form asks whether you have already expressed your wishes concerning medical treatment through either written or oral communications and, 
if not, whether you would like to do so now. The second section of this form provides
an opportunity for you to discuss your values, wishes, and preferences in a number of 
different areas, such as your personal relationships, your overall attitude toward life,
and your thoughts about illness.

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 or Durable Power of Attorney, if you have one, or filing the Values History Form with your important medical papers. 

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

(212-246-6973) 

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 large volume of requests, expect a 4‑6 week turnaround 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. 

WHO SHOULD CONSIDER PREPARING A VALUES HISTORY 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.

The Values History Form was developed at the Center for Health Law and Ethics, University of New Mexico School of Law. The form is not a legal document, although it may be used to supplement a Living Will or a Durable Power of Attorney for Health Care, if you have these.  Also, the Values History Form is not copyrighted, and you are encouraged to make additional copies for friends and relatives to use.