NOTES FOR COMPLETION 2 COLUMNS - Health and Social Services

3. Personal Care Wishes
My wishes regarding personal care are:
(Examples: • death at home if possible • admission to a care facility if necessary)
4. Personal Values
It is not usually possible to foresee in advance all of the types of health care
decisions which may have to be made for you. Use this space to express any
personal beliefs or values that you think will help your proxy understand and follow
your wishes:
(Examples: • I would prefer to stay at home as long as this does not cause undue stress
on my family and caregivers • do everything possible to maintain life • my religious beliefs
are important and because of this, I want … • If I am nearing my death, I want …)
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