Record your advance directives
Coming soon!
Interviewer instructions:
For all questions, read both the bold text and examples to the interviewee. Click “Record” below each question to capture a video of the answers.
Who would you want to make health decisions for you if you became incapacitated?
(specify full name(s), relationship(s), and how to best reach them)
| RECORD | PLAY | DELETE | SAVE |
If you suddenly keeled over, had no heartbeat, and were not breathing, what would you want done?
(for example “Call 911” or “Call the undertaker”)
| RECORD | PLAY | DELETE | SAVE |
Describe your feelings about having a PERMANENT feeding tube if you weren’t able to eat for yourself.
(for example “I want one to keep me alive even if I’m unconscious and unlikely to recover” or “I never want to have a permanent feeding tube”)
| RECORD | PLAY | DELETE | SAVE |
Describe your feelings about having a TEMPORARY feeding tube if you weren’t able to eat for yourself.
(for example “I want one if there is a chance my condition will improve” or “I never want to have even a temporary feeding tube”)
| RECORD | PLAY | DELETE | SAVE |
Describe your feelings about being put on a PERMANENT breathing machine if you weren’t able to breathe for yourself.
(for example “I want one to keep me alive even if I’m unconscious and unlikely to recover” or “I never want to be put on a permanent breathing machine”)
| RECORD | PLAY | DELETE | SAVE |
Describe your feelings about being put on a TEMPORARY breathing machine if you weren’t able to breathe for yourself.
(for example “I want one if there is a chance my condition will improve” or “I never want to be put on even a temporary breathing machine”)
| RECORD | PLAY | DELETE | SAVE |
Give at least one specific example explaining why you made the choices above.
(for example “My husband had a feeding tube against the advice of others and he made a complete recovery” or “My aunt suffered greatly on a breathing machine and never got better before she died”)
| RECORD | PLAY | DELETE | SAVE |
Finalize
| PLAY ALL | CONFIRM & SIGN |
Share
| DOWNLOAD ALL | EMAIL ALL |
Notes:
1. Must be HIPAA compliant for health care use.
2. Need record, play, delete, and save capabilities.
3. Must be able to save files on my server.
4. Need capability to retrieve files from my server.