Make room for the person’s values, chosen decision support and practical care questions before an urgent choice arises. Keep conversations, documents and care arrangements connected.
Evidence checked October 18, 2026 (America/Denver). Version 1.0. Original-source desk review; no practical testing.
What this guide helps you do
Conversation and resource navigation. Appropriate treatment, capacity, proxy authority, document formalities and service coverage depend on the actual person and jurisdiction and need suitable professional guidance.
Begin with values and preferences
Ask what matters to the person, what they want others to understand and how they prefer to discuss difficult choices. NIH’s planning article connects an advance-care plan with personal values and trusted people. Use a conversation that the person can take part in, with the communication support they want. Source: NIH MedlinePlus advance-care conversation checklist.
Separate wishes from authority to act
MedlinePlus introduces treatment-wish documents and a health-care proxy as distinct planning elements. Ask the care team and an appropriate legal adviser which documents fit the situation, who may act and when, and what the person should understand before signing. A family relationship or an informal planning note should not be treated as proof of legal authority. Source: MedlinePlus advance directives introduction.
Confirm the actual document requirements
Find current, appropriate forms through the responsible provider, official state resource or qualified legal adviser. Ask about signatures, witnesses, notarization, review and replacement requirements for the actual document and jurisdiction. The NIH checklist’s broad notarization statement is not a universal instruction; this guide does not validate a form or execute one. Source: NIH MedlinePlus advance-care conversation checklist.
Discuss care and everyday support together
The NIH end-of-life overview includes physical comfort, emotional and spiritual needs and practical tasks. Ask the care team about appropriate palliative or hospice support, available settings and how care would be coordinated. Include what chosen family or helpers can realistically do, their need for support, and actual costs or coverage questions. Source: NIH MedlinePlus end-of-life support overview.
Make the current plan findable
Keep a private index of the current documents, their location and the responsible contacts. Ask the provider how to place appropriate copies in the care record and how a chosen helper can find them when needed. Decide who should know the location while keeping private medical and financial details protected. Source: NIH MedlinePlus advance-care conversation checklist.
Revisit the plan after changes
Set a review date and discuss the plan again when wishes, health, relationships or available support change. Ask the appropriate professional how to update records and replace superseded directions. When a care question becomes urgent, use the actual care team rather than trying to resolve treatment or authority from this worksheet.
A record you can use
| Record | What to write down |
|---|---|
| Values | What matters and how the person wants to communicate |
| Decision support | Chosen helper and authority questions for professional review |
| Documents | Appropriate form, execution and update requirements to confirm |
| Care support | Setting, coordination, comfort and caregiver questions |
| Private index | Current version, location and who may find it |
| Next discussion | Responsible professional, unanswered question and review date |
Learning route
- Hear preferences: Start with the person’s values and communication needs.
- Clarify documents: Ask about suitable forms and decision-making roles.
- Arrange support: Discuss care, practical help and actual conditions.
- Keep it current: Maintain a private index and review after changes.
Checklist
- The person’s own wishes are recorded.
- Document and authority questions have appropriate professional help.
- Execution requirements are checked for the actual jurisdiction.
- Care and practical support are discussed together.
- The current plan can be found by the right people.
- Review and update arrangements are recorded.
Resources and their limitations
MedlinePlus advance directives introduction
MedlinePlus advance directives introduction — US National Library of Medicine / NIH
Use. Use the summary’s distinction between treatment wishes and a health-care proxy to prepare a conversation with the care team and an appropriate legal adviser.
Access and cost. Public source reading. Actual professional advice, accounts, products and services can have separate costs and conditions; no personal cost, coverage or outcome determined.
Review and limits. No substantive revision date established in retrieved text. Summary and gateway only. Linked legal/medical sources, forms, procedures, treatment options and studies not reviewed. No capacity, clinical choice, proxy authority or document validity determined.
NIH MedlinePlus advance-care conversation checklist
NIH MedlinePlus advance-care conversation checklist — US National Library of Medicine / NIH MedlinePlus Magazine
Use. Use the values, proxy and document-location prompts to prepare questions. Confirm the appropriate form and execution requirements with a qualified professional for the actual jurisdiction.
Access and cost. Public source reading. Actual professional advice, accounts, products and services can have separate costs and conditions; no personal cost, coverage or outcome determined.
Review and limits. Originally April 2018; updated article dated November 1, 2024. Its blanket notarization instruction is not adopted: actual formalities vary and were not checked. Linked conversation guide, forms and NIA pages not read. No medical decision, legal validity or care outcome assessed.
NIH MedlinePlus end-of-life support overview
NIH MedlinePlus end-of-life support overview — US National Library of Medicine / NIH MedlinePlus Magazine
Use. Use the care/support categories and setting questions to discuss the person’s preferences, appropriate professional help, coordination and actual costs or coverage.
Access and cost. Public source reading. Actual professional advice, accounts, products and services can have separate costs and conditions; no personal cost, coverage or outcome determined.
Review and limits. Dated November 1, 2024. Selected support, setting and team-conversation portions only. Symptom management, prognosis, hospice eligibility, dementia guidance, substitute decision authority and linked clinical/legal material not evaluated or prescribed. No provider, service availability or coverage confirmed.
Historical starting point
The Spring 1969 Person to Person review combines professional writing with lived experience. Modern advance-care conversations extend that attention to the person’s own perspective. Historical therapy claims, anecdotes and diagnostic ideas are not used to assess capacity, choose treatment or establish legal authority. Locator: Whole Earth Catalog — Spring 1969, PDF page 84, printed page 82.
Related guides
- Planning for changing capacity
- Caregiving plans and shared responsibility
- Care services and provider evaluation
Last substantive desk review: October 18, 2026. Sources retain their own dates and geographic limits. Local services and individual products require a fresh check at the time of use. For a correction, retain the page title, source and passage in question.
