|#||Domain||Examples of questions|
|1||Identification||How do you prefer to be called? Where do you come from? Profession? Married? Children?|
|2||Surrogate||If you were not able to make decisions, with whom would you want physicians to discuss your medical condition? Who would you want to make decisions for you?|
|3||Preferences about receiving medical information||
What are your preferences about receiving medical information? If we had bad news, would you want to know about it or should we discuss it just with your family?|
Are you the kind of patient who appreciates knowing all the details about your disease, or do you prefer to know just the big picture and that I talk about the details with someone else?
|4||Preferences for participation in medical decisions||What are your preferences for participation in medical decisions that may possibly involve life threatening situations or risk of permanent disability?|
|5||Relevant values and view of suffering||
What is important for you? How is your life outside the hospital? What are you hoping for? What are your biggest concerns right now? What is the hardest part of being ill for you? And for your family? Given what we are facing, what is your main goal? (for patients who answer “to be cured”, after acknowledging hope, healthcare providers can ask “what else?”).|
Other relevant values that could be explored: values about maintenance of bodily integrity/ physical well-being/functional status/ independence / cognitive function /autonomy and independence / social and emotional engagement/ avoiding burdensome physical symptoms.
Spirituality might be learned by using acronyms for obtaining a spiritual history. For example, FICA or SPIRIT:
F: Faith and beliefs
I: Importance of spirituality in the patient’s life
C: Spiritual community of support
A: Addressing the patient’s spiritual issues in
his or her care
S: Spiritual belief system
P: Personal spirituality
I: Integration with a spiritual community
R: Ritualized practices and restrictions
I: Implications for medical care
T: Terminal events planning
|6||End of Life preferences||If facing a terminal and irreversible illness, how would you like to be cared for? Would you prefer to have your life prolonged even if that could involve suffering and no quality of life? Or should we try to attempt to prolong life as long as some functional independence is possible? Or should we let nature take its course, focusing just on the relief of suffering? Should we solely focus on minimizing suffering and pain, even if it eventually may hasten death?|
|7||Allowing space for comments and clarification of doubts||
Did I forget to ask something important?|
Would you like to tell me anything else?
What did you think about this conversation?