Living Will for Dementia video link

FREE: "My Way Cards: Introduction for Professionals" e-book

For professionals on National Health Care Decisions Day:

Natural Dying Living Will Cards front conver

Psychiatrist Dr. Stanley Terman, the founder and medical director of Caring Advocates, (a non-profit organization) is pleased to present TWO offerings:

  1. A FREE professional e-book version of the Natural Dying Living Will Cards: Available in a variety of formats: epub, Kindle ($0.99), Nook, PC, MAC, and smartphones. (The free "Apps" are provided by Amazon or Barnes & Noble.)
  2. A FREE webinar for professionals that focuses on Advanced Dementia. The one-hour program begins with why Advanced Dementia is such a huge but important challenge. It continues with a demonstration of how Natural Dying Living Will Cards can facilitate planning. The format can include audience participation by audio—via internet or by phone. Available times are 9 am, Noon and 4 pm (Pacific Time)—depending on when people wish to participate. If you are interested in attending, contact Dr. Terman at DrTerman@gmail.com or 800 647 3223.

Do you know what it is like to live with Advanced Dementia?

Can you answer, "At what point do you want to stop receiving life-sustaining treatments if they will only prolong your dying and they might increase your pain and suffering?"

The items on Natural Dying Living Will Cards provide a glimpse of how Advanced Dementia may affect you and others. If you suffer from this devastating disease someday, by then it will be too late to tell others what you want...

Sorting Natural Dying Living Will Cards/My Way Cards can provide your future decision-makers with your Known Wishes about your preferences based on your personalized criteria of Advanced Dementia or other terminal illness.

Advance Directives that use specific clinical diagnoses and definite medical interventions risk different interpretations and thus prolonged arguing, the result of which can be To Delay is To Deny. To avoid giving future "experts" any issues to argue about, Natural Dying Living Will Cards/My Way Cards use NO clinical diagnoses. Instead, cards have words that strive for clear and convincing descriptions of choices you may want. Similarly, the intervention requested, Natural Dying™, unambiguously and simply requests all the Comfort Care you may require, while withholding all life-sustaining treatments including all food and fluid by any route.

Learn Before You Decide


Links to use with ebooks


Some thinking/memory problem?


My Decisions Table


Submit your personal data from a MyWayCards wallet card or My Decisions Table


Brochure


Getting Started


Directions for Use
(pdf)


Why we need Natural Dying Living Will Cards


Criteria Overview


How to Order Natural Dying Living Will Cards


Why sort twice?


How to rearrange cards.


Professionals, click here


Where do you start, for a peaceful transition


Powerpoint presentation: The effectiveness of sorting MyWayCards
 

List of Resources for a Timely, Peaceful Transition

  • If you do NOT want to linger in Advanced Dementia or another terminal illness…
  • If you DO want total relief from unending, unbearable pain and suffering…
  • If you want to reduce the stress and suffering of your loved ones…

Check out the VIDEOS at YouTube “DrTerman, channel” or “Plan Now, Die Later-Peacefully, channel” for personal viewing. For public viewing and DVDs, contact Caring Advocates. (Unless noted otherwise, production date & copyright 2011; time about 30 min.)

  1. A Living Will for Alzheimer’s Dementia: it’s easy and effective. (Why consider the Natural Dying--Living Will. 11 minutes.)
  2. Prevent lingering in Advanced Dementia; unbearable pain & suffering; futile hospitalization-in 2 min. (A physician expresses a clinical opinion that emergency department physicians and clinicians responding to emergencies—911, 999, 112—can access rapidly.)
  3. To Prevent Prolonged Dying & Pain in Alzheimer’s Dementia & Terminal Illnesses:  
    I. Challenges to Natural Dying
    .  
  4. To Prevent Prolonged Dying & Pain in Alzheimer’s Dementia & Terminal Illnesses:  
    II. Strategies for Natural Dying
    .
  5. To Prevent Prolonged Dying & Pain in Alzheimer’s Dementia & Terminal Illnesses:  
    For UK residents
    .
  6. WHEN WE DIE: Does Physician-Assisted Suicide/Dying Always Mean Dying is Timely? (Interactive; uses excerpts from Sir Terry Pratchett’s video, “Choosing to Die.”)
  7. MyLastWishes.org: To Rapidly Inform & Convince Clinicians to HONOR Emergency Orders and Known Wishes. A way to display & retrieve clinical and strategic forms, and play videos of you and your physician. (Currently a “private video”; must be requested.)
  8. For a Living Will that is Effective for Advanced Dementia & Terminal Illnesses, sort “Natural Dying Living Will Cards”. A diligent way to express end-of-life wishes and to prove that your mind was “sound.” (15 min.)
  9. For a Living Will Effective for Dementia & Terminal Illnesses, Sort Natural Dying Living Will Cards. A diligent way to express end-of-life wishes and to prove that your mind was “sound.” (15 min.)
  10. Making Hard End-of-Life Decisions for Your Loved One: Can All Agree by Sorting Natural Dying Cards? The method introduced has two goals: to make the same decision the patient would, and to reduce the stress of loved ones/decision-makers. (11 min)
  11. FASTING—A Legal, Peaceful Way to Avoid a Prolonged Dying with Pain and Suffering. Recorded as Dr. Terman’s personal fast ended. Shows how to relieve thirst. Includes a clip from TV’s “Boston Legal.” (2007; 25 min.)
  12. At the Bedside of a Peaceful Transition. A loving partner’s point of view. (2008; 11 min.)
  13. Toward an Ironclad Plan for Dementia. Presentation in Toronto. (2006; 53 min.)

Books:

Peaceful Transitions: Plan Now, Die Later—Ironclad Strategy and Peaceful Transitions: Stories of Success and Compassion (2011; Second Edition). Available as two separate, smaller books, or as one larger, combination book at www.CaringAdvocates.org, Amazon, Barnes and Noble—in paperback, hardbound, and e-book formats. This book extends the topics covered in The BEST WAY to Say Goodbye: A Legal Peaceful Choice at the End of Life (2007).

The book Peaceful Transitions provides detailed information about the oppositions’ challenges and strategies to overcome them; describes how to complete strategic forms, includes guest essays and sample arguments, suggests how to select a trustworthy proxy, and reveals a private way to find out if one might have “a little” dementia. More info: www.PeacefulTransitions.com

Clinical and strategic forms.

These forms almost always work with other Living Wills and your state’s required forms:

  1. Natural Dying—Living Will (generated by sorting My Way/Natural Dying Cards);
  2. Natural Dying Advance Directive combined with the Natural Dying Physician’s Orders;
  3. Consent Form to Relieve Unbearable Pain by Palliative Sedation;
  4. Natural Dying Agreement and Natural Dying Affidavit;
  5. Natural Dying Explanation and Commitment (for skilled nursing and assisted living facilities); and,
  6. Designation of Proxies/Agents; Specifying their Authority.

 

To Store and Retrieve your forms and additional information:

www.MyLastWishes.org is the name of a website and a new program that lets clinicians rapidly view emergency orders; obtain downloads/faxes of your clinical and strategic forms; and view videos by you and your physician. You can avoid unwanted treatment; increase your chances of surviving a medical emergency; provide your contact information including your address and map (if you get lost); and play videos that will convince others to HONOR your Known Wishes so you can attain the goal of a timely, peaceful transition.

E-Mail: DrTerman@gmail.com SKYPE: stan_terman
UK direct phone: 44 20 8123 7106; Australia direct phone: 61 03 9016 4284

 

To make sure you understood how to sort Natural Dying Living Will Cards/My Way Cards,
and to see if you learned what you need to know,
from sorting them.

1) Are you worried if a thinking/memory problem could be serious?
SAGE is a brief, self-administered cognitive screening instrument to identify Mild Cognitive Impairment (MCI) and early dementia. Average time to complete the test is 10 to 15 minutes.
Take SAGE Test (opens in new page: Ohio State Univeristy - Department of Neurology)

2) A quick test of "Health Literacy" -- your general ability to understand medical forms.

Natural Dying Living Will Cards/My Way Cards/b> are for many kinds of people. Some people know a lot about other areas of life, but happen to be weak in the area called, "Health Literacy." Researchers showed that people who have LOW Health Literacy can understand their options better if someone helps them complete the forms. This is particularly important for people who are ill or have mild trouble with their thinking or and/with their memory.

The question is, "Do you need help sorting Natural Dying Living Will Cards/My Way Cards?" You should answer this important question BEFORE you sort Natural Dying Living Will Cards/My Way Cards.

As a guide to determine if your Health Literacy may be low, click here to download the test called, "METER" the "Medical Term Recognition Test") developed by Katherine Rawson, and her colleagues. (Rawson KA, et al. The METER: A Brief, Self-Administered Measure of Health. J Gen Intern Med (2009) 25(1):67-71.)

After you complete the METER, click here to download the scoring form. Use it to see how well you did. This page also offers some general guidelines regarding your need for help. Keep in mind however that the best judge of your ability to understand is a psychologist, physician, psychiatrist, or counselor, who knows you well. This quick test is "just a guide," but it may encourage you to ask for help, if you need it. It may also provide evidence to help prove you did understand the decisions you made by sorting Natural Dying Living Will Cards.

3) A quick test of what you learned from sorting Natural Dying Living Will Cards/My Way Cards.

Many people complete very important forms that could determine how long they receive life-sustaining treatment. Surprisingly, it is NOT common for their physicians or others to ask them specific questions to make sure they really understood the basic information they need to make such decisions.

Natural Dying Living Will Cards/My Way Cards teach about three areas: Living Wills, Natural Dying, and Advanced Dementia.

The "Knowledge Test" is a new 20-item True/False questionnaire. You can take it either before or after you sort the cards-or better yet-both before AND after.

Click here to download the "Knowledge Test." You might want to print it twice.

After you have taken the test, click here to download the "Knowledge Test scoring form" to see how well you did. If you missed ANY important question, consider discussing this item with your physician, your counselor, or your Caring Advocates Clinical Facilitator.

Skype Me™!
International callers: If you have Skype, or if you'd like to, click this button to call On-Phone Assistance.

If you have a Skype phone, you can dial directly: +990009369991446675

On-Phone Assistance

...is ready when you are.
When to listen:
Some people listen to these informative messages just as they are about to select one of the four My Choice Cards (A, B, C or D) during their first sorting.
Others prefer to listen between the first and second time they sort, to have time to think about the consequences of each selection.

How to connect and select:
There are four ways to listen to "On-Phone Assistance."
A) If you can dial the US number, it is 1-206-388-5109.

B) International callers can use SKYPE from their computer (which is free). Our number is so long we provide a button (above or below) for you to click.
TIP: You need a "Dial Pad" to make numerical selections. A "Dial Pad" will appear in the upper right-hand corner if you click on the phone number that was automatically dialed in the upper left-hand corner.

C) To listen to the audio MP3s on your computer, click any numbered selection below.
(Note to Caring Advocates Planning Professionals: Select a connection method that is suitable for your clients.)
  1. What does Advanced Dementia look like? (#1);
  2. What do we mean by Natural Dying? (#2);
  3. What does stopping Manual Assistance with Oral Feeding looks like, at the bedside? (#3);
  4. How do I choose a My Choice Card that is RIGHT for me?

    Listen to more information on Choice... A (#4); B (#5); C (#6); and D (#7).
Skype:
Skype Me™!

Highly recommended:

Watch Video: Advanced Dementia from Angelo Volandes, MD

A 2-minute video that Angelo Volandes, MD, and colleagues used in several research studies to study decision-making about what kind of care (Aggressive Care versus Comfort Care) people will choose for themselves--if they reach the stage of Advanced Dementia.
(Reference: Volandes AE et al. Video decision support tool for advance care planning in dementia: randomised controlled trial. BMJ 2009;338:b2159.)

I refer to this important video as, "What a difference two minutes can make." It makes a great impact on viewers changing their mind regarding their choice of aggressive care in Advanced Dementia. Interestingly, it illustrates only a few symptoms of Advanced Dementia. They are: unable to communicate understandably with others, unable to move around or walk or get out of bed independently, unable to eat by themselves and have difficulty chewing or swallowing. (In contrast, there are 47 items in the deck of Natural Dying Living Will Cards.)

Watch Video

 

Brochure for Natural Dying Living Will Cards
Note that this information is available for download.

To create an effective Living Will, sort Natural Dying Living Will Cards/My Way Cards

Most of us, when we think of Advanced Dementia, do NOT want to a prolonged process of dying, with its burdens to ourselves and others. We'd prefer to avoid its symptoms, losses of function, unwanted behaviors, and conflicts with life-long values. But can we answer this:

"At what precise point do I want to stop receiving all life-sustaining treatments-if they will just prolong my dying and are likely to increase my pain and suffering?"

The problem: Advanced Dementia is irreversible and progressive: it cannot be cured and it will certainly get worse. In the moderate stage of dementia, however, many patients still enjoy some aspects of their lives. So how can your future decision-makers and your loved ones be sure that the time has come to Permit Natural Dying-to withhold all life-sustaining treatments including all food and fluid by all routes, while they still provide you with ALL the Comfort Care you need?

The solution: Each Natural Dying Living Will Cards/My Way Cards describes a single item by a few simple words and a cartoon-like illustration. Sort them to indicate your preferences for your future decision-makers to use as a GUIDE to determine WHEN to Permit Natural Dying. Sorting Natural Dying Living Will Cards/My Way Cards also lets you choose just how strongly you want future decision-makers to honor your current instructions versus to consider other future factors.

The challenge: If a health care provider or an institution opposes honoring your wish to refuse manual assistance to eat and to drink, you may be forced to endure a prolonged dying. Your loved ones may face a long, difficult legal conflict. To prevent challenges where "To Delay is To Deny," you must provide solid evidence that will meet the consistent, clear and convincing standard in civil courts. Sorting Natural Dying Living Will Cards/My Way Cards can help your future decision-makers prove that you willingly, voluntarily, diligently, and competently expressed your Known Wishes in terms of the precise condition for which you do, or do not, want specific treatment. Even the strictest court should honor your wishes... quickly!

Recommendations: To memorialize your diligent and competent selection of preferences, create an audio- or video-recording of your comments as, or right after you sort the cards: with your loved ones, your proxy/agent, or a planning professional. Follow the instructions to create your wallet card; then send a copy or a FAX or upload it to Caring Advocates to create your Natural Dying-Living Will. Sign this form in front of two qualified witnesses or a notary. (Note: Patients in early dementia usually need a formal psychiatric evaluation to prove they possessed the mental capacity to make end-of-life treatment decisions.)

Next steps: Discuss your choices on the Natural Dying-Living Will with your loved ones, proxies, and physician. Complete an Natural Dying Advance Directive, which lets you empower either your proxy and/or your physician to decide WHEN to Permit Natural Dying. It also allows you to list individuals whom you wish to disqualify as future decision-makers. Ask a physician to sign your Natural Dying Physician’s Orders for future implementation. This form lets you give your signed consent for Palliative Sedation-if you would prefer to be unconscious rather than to experience unbearable end-of-life pain and suffering if all other means of treatment cannot provide relief. Each proxy and you can also sign a Patient/Proxy Contract of Agreement. This will enhance your proxy's legal standing. To alert Emergency First Responders that you do NOT want CPR, or any IV or oral hydration, you may wish to order jewelry that you will someday wear. The Natural Dying DNR Medallion can prevent inadvertent sabotage of your plan for a Peaceful Transition. Finally, you can upload all your forms to a national registry so that authorized people can access them by FAX or Internet, when needed.

For any disease: Sorting Natural Dying Living Will Cards/My Way Cards allows you to indicate WHEN to Permit Natural Dying for any illness-if pain and suffering are unbearable, or if medical treatment becomes non-beneficial ("futile").

Other uses: You may also wish to sort Natural Dying Living Will Cards . . .
  1. After you are sure about your preferences, use two decks of Natural Dying Living Will Cards/My Way Cards to sort with each proxy/agent-to be confident that he or she understands exactly what you will want someday.
  2. If a member of your family is now suffering from Advanced Dementia but left no clear prior instructions, those people who are close and concerned can simultaneously sort a deck of Natural Dying Living Will Cards/My Way Cards. The results can be anonymously tallied to strive for a consensus of opinion regarding what the patient would have wanted-based on the most likely way s/he would have applied his/her life values, or based on what seems to be in his/her best interest. A professional facilitator may provide needed help when making difficult decisions.
More Information: A 21-minute video explains how to sort Natural Dying Living Will Cards/My Way Cards. View it for free at www.MyWayCards.org. (Video DVDs are also available.) This site has other information and a way to purchase cards through Caring Advocates, a non-profit organization whose mission is to help people decide what their end-of-life wishes are, and to facilitate fulfilling their wishes. The site www.CaringAdvocates.org offers lectures, articles, surveys, and the videos, "Fasting: A Legal Peaceful Way to Avoid a Prolonged Dying," and, "At the Bedside of a Peaceful Transition." Some levels of Caring Advocates' memberships include books. Peaceful Transitions: A Successful, Compassionate Strategy for Life's Final Challenge (2009) has explanations and stories about each component of the "ironclad strategy." The BEST WAY to Say Goodbye: A Legal Peaceful Choice at the End of Life (2007) considers fasting as a way to avoid a prolonged process of dying from every standpoint-clinical, emotional, relational, legal, moral, ethical, religious, and political. BEST WAY explains five significant advantages of fasting from all food & fluid over Physician-Assisted Dying (Suicide): 1) Fasting is legal everywhere; 2) No physician permission is required; 3) Fasting works for physically incapacitated patients; 4) Patients often have several days to change their minds; 5) The process allows time to exchange healing goodbyes.

Ethical and moral perspective: It is ironic that a clear and convincing description about WHEN to Permit Natural Dying not only can prevent a prolonged process of dying with its accompanying pain and suffering and other burdens; it also can prevent a premature dying. Caring Advocates' mission is a "WHEN to die" where the timing is neither prolonged nor premature, and a "HOW to die" where the dying experience will be as peaceful as possible for both patients and families.

By mid-Century, the U.S. will be overwhelmed with the financial burden to care for 5 million patients with Advanced Dementia that some may state we no longer can afford. But can we imagine letting someone die just for lack of funds? Yet we must respond to a person's expressed choices for which particular symptoms, losses of function, unwanted behaviors, and conflicts with life-long values of Advanced Dementia they do not want to endure. Our obligation to Permit Natural Dying is not only kind and compassionate; it is totally consistent with medicine's oldest principle: FIRST, DO NO HARM.

For more information, or to order one or more decks of cards: call us, send us an email, or visit us at www.MyWayCards.org.
Stanley A. Terman, Ph.D., M.D.
DrTerman@gmail.com

www.CaringAdvocates.org
800 64 PEACE (800 647 3223)

www.PeacefulTransitions.com
Share your story at NaturalDyingWiki.org


Getting Started with Natural Dying Living Will Cards/My Way Cards

Let's assume you are competent and have a primary care physician (even if s/he is rather busy).
  1. View the 21-minute video on Natural Dying Living Will Cards/My Way Cards on www.MyWayCards.org. Consider also reading other material on that web site. If this sounds like it might be a good plan...
  2. Ask your primary care physician to send you his/her standard form to consent to release confidential medical information. If you sign it, you will be giving your permission for a professional from Caring Advocates to call your physician and explain how s/he can complete Advance Care Planning in an efficient and effective way. It is best to do this ahead of time. You can always revoke this permission if you change your mind.
  3. Sort the Natural Dying Living Will Cards/My Way Cards to create your Wallet Card. Usually this takes less than a half-hour.
  4. Send the numbers on your Wallet Card to Caring Advocates by following the instructions in the cards. (They will explain your options: you can copy and send, fax, or upload to our secure site.)
  5. Caring Advocates will send back your Natural Dying-Living Will and other Advance Care Planning documents that are relevant for your State.
  6. Consider completing the Natural Dying Advance Directive (NDAD) by answering, "Yes," to its question, "Did you express your specific wishes for Advanced Dementia by creating a Natural Dying-Living Will?" If you decide to use the NDAD, attach your Natural Dying-Living Will.
  7. Sign your NDAD in front of two qualified witnesses or a notary.
  8. Read over the Natural Dying Physician’s Orders (NDPO) and decide if you want its four orders to be implemented someday in the future by your physician and/or agent/proxy.
  9. If so... make an appointment with your primary care physician and bring him/her the NDAD and the Natural Dying Physician’s Orders, and your Natural Dying-Living Will. (You might mention that your physician can probably be reimbursed for his/her time by using the billing code, V65.49, "Other specified counseling," as long as this activity took more than half of your office visit.)
  10. After your physician signs the Natural Dying Physician’s Orders, follow the "Next Steps" card in the deck of Natural Dying Living Will Cards (or the guidelines in the book, Peaceful Transitions: A Successful, Compassionate Strategy for Life's Final Challenge.) Examples: you may wish to add a Proxy Directive that works in your State for other instructions, a Patient/Proxy Contract of Agreement to enhance the "ironclad strategy," order a Natural Dying DNR Medallion to emergency first responders will know what to do and what not do (but do NOT wear it until "that time comes"), and upload all your Advance Care Planning Documents to a national registry so that authorized people call retrieve them expediently, when needed to make critical decisions-which registration (for life) is included with the purchase of a Basic Membership in Caring Advocates for $20, plus a fee of $20 annually thereafter.
  11. You can email or call us at Caring Advocates for guidance along the way: DrTerman@CaringAdvocates.org, or 800 64 PEACE (647 3223)



Why We Need “Natural Dying Living Will Cards/My Way Cards”


My attorney colleagues taught me something of great value: A single signature at the end of a long and complicated document could be challenged on this basis: lack of evidence that the person who signed really understood all the fine points in this long and complicated document. While the Criteria of Advanced Dementia to Consider Natural Dying was subjected to the review of several professional colleagues, in its compact form (on page 52), someone could in the future, challenge the process of decision-making on a similar basis, if the then-competent person merely responded “No” to the question, “Do you want to modify these criteria?”—This is the legal reason why I developed Natural Dying Living Will Cards.

The clinical reason why I developed the Natural Dying Living Will Cards/My Way Cards was that it was rare that anyone modified the Criteria of Advanced Dementia to Consider Natural Dying. At first, I hoped people were comforted by these words on the Natural Dying Advance Directive: “to use as a guide.” But as a psychiatrist, I was worried: the list is obviously not pleasant so it is likely that people would rather not consider each item for a long time. Moreover, they might be overwhelmed by reading all these diverse manifestations of Advanced Dementia on a single sheet of paper. And they were really diverse: symptoms like apathy and difficulty swallowing; behaviors such as agitation and incontinence; functional losses like being unable to recognize loved ones or communicate; and conflicts with life-long values such as being a financial and caregiving burden to one’s family while not being able to appreciate any benefit from living.

A list with boxes to check seemed too small an improvement. People might still feel overwhelmed if asked to make three dozen “Yes” or “No” decisions (on three sheets of paper).  Then I considered Dr. Elizabeth Menkin’s Go Wish Cards, whose goal is to facilitate discussions about end-of-life desires. Her cards ask you to first select the wishes you consider “very important,” then to choose the “ten wishes that mean the most,” and finally to rank those ten in order. However several wish-cards seem universal, like “Not dying alone” and “To be kept clean.” Most of the cards assumed the patient would NOT die suffering from dementia. (Examples: “To remember personal accomplishments,” and “To have someone who will listen to me,” and “To be able to talk about what death means.”) Moreover, the cards did NOT seem designed to help guide future decisionmakers. These two wishes, for example—“To be free of pain” and “To be mentally aware”—were NOT considered as being in direct conflict with each other if future decisionmakers must someday give consent for Palliative Sedation.

Guiding future decisionmakers is the primary goal of Natural Dying Living Will Cards/My Way Cards. During Advance Care Planning, a competent person sorts the cards into two stacks: the “YES” stack will include the symptoms, behaviors, functional losses and conflicts in life-long values they DO want their future decisionmakers to consider as they determine WHEN to Permit Natural Dying. The “NOT” stack includes those items they do NOT want considered. (It is fine if some cards are not used for either stack.) To make the messages on the cards both easier to appreciate and more impactful, each card has an illustration or photograph on its back. (See example on next page.)

As a final step, the person diligently reviews each “YES” card as s/he asks the question, does this card—by itself—warrant consideration that it might be time to Permit Natural Dying? If the answer is “Yes,” the person circles the number of this card on the Natural Dying Living Will Cards/My Way Cards—Results form. (The official name for this group of circled items was By Themselves Cards, but now we refer to them as My Checkout List.) The form, Natural Dying Living Will Cards/My Way Cards—Results, can be notarized or witnessed so it can be attached and become part of, an Advance Directive.

Solitaire: Play Natural Dying Living Will Cards/My Way Cards by yourself, “to figure out what is important to you and why”—especially since the characteristics of Advanced Dementia are so variable and people such have different preferences. One card has the disclaimer that sorting cards is “no substitute for obtaining good professional advice.” Ideally, you should sort cards as you consult with a physician or Planning Professional so you have the opportunity to ask questions and to explain why you made certain choices. If you record this interview on audio or video, it can help prove that you were competent as you diligently considered your end-of-life choices.

To make sure your proxy understands: Once you know what you want, you can “play” Natural Dying Living Will Cards/My Way Cards with each of your proxies, to make sure they understand your end-of-life wishes. You and each proxy can sort the cards into “Yes” stacks; then you can both select My Checkout List cards. Finally, you can compare your results and discuss any discrepancies.

For patients who left no prior instructions for loved ones whose loved ones are being asked to consent (or refuse to consent) to potential life-sustaining treatment: Several concerned relatives, including siblings and adult children, can all sort the cards based on what they feel the patient would want in his/her current condition. They can submit their cards anonymously, which might be more honest since no one relative would need to take the “blame” for being the ultimate tie-breaker who determined to Permit Natural Dying now.

How you use Natural Dying Living Will Cards/My Way Cards is up to you. You could just write this note: “I did diligently review and I agree with all the Criteria of Advanced Dementia to Consider Natural Dying.” But if you, like many people, are worried about enduring a prolonged dying with dementia, sort the cards by yourself, ask your physician or Planning Professional to record your conversation about why you made these choices, and then sort the cards with each of your proxies.


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1. Menkin E S. (2007). Go Wish: a tool for end-of-life care conversations. J Palliat Med;10(2):297-303.


Criteria of Advanced Dementia to Consider Natural Dying


These criteria can guide your future decision-makers if you suffer from an irreversible, progressive dementia, ineffective, "futile" medical treatment, or unbearable pain and suffering. These symptoms, unwanted behaviors, losses of function, and conflicts in long-term values are grouped according to theme. Most people prefer to think about one item at a time as they engage in Advance Care Planning. Sorting Natural Dying Living Will Cards lets you inform your future decision-makers what to consider in the future, if you want them to decide WHEN to Permit Natural Dying. For more information, read Peaceful Transitions: A Successful, Compassionate Strategy for Life's Final Challenge.

1. About myself: I cannot recall or appreciate the important past events of my life. I cannot recall my life-long values. I am not self-aware. I do not respond to my name;

2. Expressing my wishes to increase my pleasure and decrease my pain: I cannot communicate any wishes by using words or gestures. I cannot make sounds or gestures to consistently indicate “Yes” or “No.” I cannot make or carry out a plan to fulfill my desires. I have no concept of my future. I cannot state if anything is bothering me so I risk suffering from untreated pain that others do not recognize;

3. Relating to others: I cannot recognize family members or cherished friends. I seem puzzled or I am wrong in identifying them. I utter no words or sounds, nor do I make any gestures, as they enter and leave my presence. I do not express any feelings of love or affection towards them. I am not able to pray to, or relate to, a Supreme Being (if I believe in One);

4. Dependency and Dignity: I am totally dependent on others for basic care. I cannot bathe myself. I cannot dress myself. I cannot feed myself. I am incontinent of urine and/or feces. My behavior no longer reflects my life-long values so I have lost my “dignity” (as I would have previously defined it); 

5. My mood, even with treatment: I rarely express joy or pleasure. I am almost always apathetic, despondent or non-responsive. I am plagued with severe fear or horror. I am agitated or aggressive without provocation. I need physical or medical restraints to prevent hurting myself or others;

6. Burdens versus effectiveness: To maintain my existence requires almost constant basic care or life-sustaining medical treatments that will not be effective to provide benefit to my overall quality of life or to allow me to live outside an institution or without being provided institutional level of care or treatment;

7. Burdens versus benefits: Prolonging the process of my dying provides me no benefit that I can appreciate, while the burdens on my loved ones/caregivers are great. Their sacrifices include: depleting their finances, diverting their attention from other important activities and responsibilities of their lives, and suffering from physical exhaustion or mental depression;

8. Regarding food and fluid: I risk contracting pneumonia by aspirating into my lungs what others put into my mouth (but I do NOT want medically-administered nutrition and hydration by tube or IV). I have lost the mental ability to know how to eat and drink. My actions indicate I am reluctant to eat. I do not seem to enjoy food. I can no longer taste and chew since my caregivers must place pureed food at the back of my tongue to make me swallow by reflex.



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Natural Dying Living Will Cards/My Way Cards:

Natural Dying Living Will Cards front conver

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SKYPE: stan_terman


See above for more information!

Why is it important to sort the cards a second time?

How can you restore the deck of cards to its original sequence?

Perspective: After sorting, people can send Caring Advocates the data on their wallet cards. They will soon receive a letter that explains the enclosures and the process:

Thank you for sorting Natural Dying Living Will Cards/My Way Cards and sending us the data from your wallet card.

Enclosed is your Natural Dying--Living Will.

We recommend you consider this Natural Dying--Living Will as your FIRST draft.

About a month from now, sort the cards again--for two reasons, which are explained below. After you send in a second wallet card from your second sorting, Caring Advocates send back, your FINAL Natural Dying--Living Will.

These are the two reasons why to sort Natural Dying Living Will Cards twice:

One reason is to "think again" so you can demonstrate that your preferences are consistent over time--in terms of your selection of symptoms, losses of function, unwanted behaviors, and conflicts with lifelong values--that you DO, or you do NOT want your future decision-makers to consider, as they determine if it is time to Permit Natural Dying.

"Thinking again" may prevent a future challenge by others who may claim that you might have changed your mind.

The other reason is to "think more deeply" about how strictly you want your future decision-makers to follow your current instructions. You can use the time between your first and second sorting to consider the pros and cons of each of the four choices represented by "My Choice Cards" A, B, C, and D. (To mention just a few examples: Perhaps you were not aware that leaving the final decision totally to your future decision-makers (which is Choice B) might cause them to feel guilt or anxiety, or lead to possible conflicts. Or you might not have appreciated that the strategy for others to honor your wishes is much stronger by choosing D and that an effective strategy is needed if you want to avoid prolonging your dying and to avoid the increased risk of experiencing unrecognized and untreated pain and suffering.)

Each choice is described by an audio message a few minutes long. You can listen to any time by calling "On-Phone Assistance" (worldwide, as explained in the letter), or by clicking on the MP3s on the website, www.MyWayCards.org.

After you listen to these audio clips, you may wish to discuss your options with your proxy, members of your family, your clergy, and/or your physician.

Thinking more deeply is important because it is not enough for your future decision-makers to know which items you want them to consider; they must also know how strictly you want them to follow your current instructions when "that time" comes.

It is not hard to restore a deck of cards to its original sequence. Here's how:

The cards are divided into four sections:

  • The first section includes cards that provide initial instructions. Except for the title card, each card in this section has a number in lowercase Roman Numerals--from ii to xii.

  • Second are the 48 symptoms, losses of function, unwanted behaviors, and conflicts with lifelong values. These cards are numbered 1.1 to 8.6.

  • Third are the cards that provide instructions on the sorting process and on creating a wallet card. These "after sorting" instructional cards are numbered in UPPER CASE Roman Numerals--from XIII to XXI.

  • Fourth and finally, there is the "Next Steps" card, information about ordering medallions, and further resources. These cards are NOT numbered because their sequence is not important. It is only important that you consider this information so you can make the best decision for yourself.



For professionals only:
If you are interested in the professional version of the Natural Dying Living Will Cards, which comes with a manual and can include online and phone training to assess whether or not your patients have decisional capacity to sort Natural Dying Living Will Cards, contact Dr. Terman at 1-800-64-PEACE (647-3223)