My Wishes

1

The Basics

Your Information

Full Name

Date of Birth

Your Healthcare Agent

This is the person you trust to make medical decisions for you if you are unable to make them yourself. Choose someone who knows you well and will respect your wishes.

Recommended: Appoint a primary agent and at least one alternate. This ensures someone is available to speak for you.

Primary Agent's Full Name

Primary Agent's Contact

Alternate Agent's Full Name

Alternate Agent's Contact

2

My Core Philosophy

My general wish on life-sustaining treatment

This is your guiding principle for treatments that postpone death (e.g., breathing machines, CPR) when you have a terminal condition or are permanently unconscious.

Focus on Comfort: No life support if the condition is terminal or I'm permanently unconscious. Prioritize pain relief.

Prolong Life: Use all available treatments to prolong my life as long as possible, no matter the circumstances.

Let My Agent Decide: I trust my healthcare agent to make the best decision for me at the time.

My wish on artificial nutrition (tube feeding)

This is providing food and water through a tube if you cannot eat or drink. It is considered a life-sustaining treatment.

No Tube Feeding: Do not use tube feeding if it would only prolong dying.

Yes to Tube Feeding: Use tube feeding to keep me alive.

Let My Agent Decide: I trust my healthcare agent to make this decision.

3

My Wishes in Specific Scenarios

If I have cancer with a poor prognosis...

This concerns aggressive treatments like chemotherapy when a cure is unlikely, which can have severe side effects.

Focus on Comfort: No chemotherapy; prioritize quality of life.

Attempt Treatment: Pursue aggressive treatment if there is any chance.

Let My Agent Decide: I trust my agent to weigh the pros and cons.

If I need major surgery with an uncertain outcome...

This applies to situations like a severe stroke or brain injury where surgery might save your life, but could result in severe disability.

No Surgery if Outcome is Poor: Decline if a meaningful quality of life is unlikely.

Perform Surgery to Save Life: Proceed even if the outcome is uncertain.

Let My Agent Decide: I trust my agent to make this complex decision.

If I am in a persistent vegetative state...

This provides a clear deadline if you are unconscious and doctors have determined there is no reasonable chance you will recover.

Let My Agent Decide: No specific time limit; I trust my agent's judgment.

Yes, after a time limit: Discontinue support after a specified period.

If you chose a time limit, please specify (e.g., 3 months, 1 year):

4

My Comfort & Values

My preference for pain management

Sometimes, high doses of medication needed to relieve severe pain might unintentionally shorten life. This addresses your priorities.

Prioritize Comfort: Relieve my pain fully, even if it might shorten my life.

Prioritize Alertness: Keep me as alert as possible, even if I have some pain.

My wishes for spiritual or personal comfort

This is an optional space to share what would bring you peace. This could be about religious rites, music, or who you want by your side.

My wish for organ and tissue donation

Your organs and tissues can be donated after death to help others. This does not typically interfere with funeral arrangements.

Learn more at the Thai Red Cross Organ Donation Centre

Yes, any needed organs/tissues.

Yes, only specific organs/tissues.

No, I do not wish to donate.

If specific, please list them here:

My thoughts on financial considerations

Expensive medical care can place a heavy burden on your family. This question allows you to provide guidance on this sensitive topic.

Finances are not a factor: Make decisions based on my health, not cost.

Consider the financial impact: Cost should be a factor in treatment decisions.

5

My Necessary Information

Blood Type

Please specify your blood type.

Special Medical Conditions

List any special medical conditions that might not be commonly known.

6

My Properties

Special instructions for your house

e.g., where are the keys, who to contact for maintenance, etc.

Special instructions for your pets

e.g., who should take care of them, their feeding schedule, vet information, etc.

Special instructions for your family

e.g., messages to leave behind, etc.

7

Funeral Ceremony

Where do you want your funeral to take place?

You can choose from the list of popular temples in Bangkok/Thailand, specify another location, or choose not to have a funeral.

How many days?

How many days should the funeral last?

Special wishes

Any other special wishes for your funeral?

8

Official e-Living Will

It is recommended to also complete the official e-Living Will from the Thai Government at https://e-livingwill.nationalhealth.or.th/