Table 2. Advance Care Planning Engagement Survey – Action Measures: Advance Care Planning Domains and Questions.
| Domain* | Questions | |
| DM | - Have you already decided who you want your medical decision maker to be? | |
| - Have you already formally asked someone to be your medical decision maker? | ||
| - Have you talked with your doctor about who you want your medical decision maker to be? | ||
| - Have you signed official papers naming a person or group to make medical decisions for you? | ||
| QOL | - Have you already decided whether or not certain health situations would make your life not worth living? | |
| - Have you talked with your decision maker about whether certain health situations would make your life not worth living? | ||
| - Have you talked with your doctor about whether certain health situations would make your life not worth living? | ||
| - Have you signed official papers about your wishes for medical care if you were seriously ill or dying in writing? | ||
| Flexibility | - Have you decided how much flexibility to give a medical decision maker if they have to make decisions on your behalf? | |
| - Have you talked with your medical decision maker about how much flexibility you want to give her/him? | ||
| - Have you talked with your doctor about how much flexibility you want to give your medical decision maker? | ||
| - Have you signed official papers to put your wishes about how much flexibility to give your decision maker in writing? | ||
| Ask Questions | - Have you decided on questions you will ask your doctors to make good medical decisions? | |
| - Have you ever ask your doctor about the risks of treatment | ||
| - Have you ever ask your doctor about the benefits of treatment | ||
| - Have you ever ask your doctor about your other options to the treatments the doctors were suggesting? | ||
| - Have you ever ask your doctor about what your quality of life would be like after starting a treatment? | ||
| - Have you ever ask your doctor about to repeat information if you did not understand it the first time? | ||
*
Decision Maker (DM), Quality of life and what is most important in life (QOL).