TABLE 4.

Questions for Clinical Assessment

Q1:	What is an advance directive?
A:	A legal form that helps doctors and family members understand wishes about healthcare at a future time.
Q2:	What is a good thing about having an advance directive?
A:	It can help your doctors and family decide about treatments if you are too ill to decide for yourself, following your values and wishes.
Q3:	What does a healthcare agent or proxy do for you?
A:	Makes healthcare decisions [if appropriate, inquire about potentially serious outcomes of such decisions].
Q4:	What persons would you consider to be your agent?
A:	[Specific to person: any adult the person knows and has a social relationship with, such as spouse, adult child, parent, sibling, grandparent, grandchild, or a close friend].
Q5:	Who would you choose as your agent?
A:	[Specific to person]
Q6:	Why would you choose/trust this person?
A:	[Specific to person: identifies someone the patient trusts, knows values, will respect wishes]. (Examiner should attend to undue influence or coercion.)
Q7:	[Ask only if the person names someone who is involved in conflict or abuse, or someone about whom there is concern regarding the agent’s capacity to be an appropriate agent.] Some people are concerned that your family member/friend may not be the best person because. Can you explain to me how you think about that?
A:	[Specific to person]
Q8:	Do you have to fill out an advance directive?
A:	No.
Q9:	Why do you want or not want to do it?
A:	To have someone to make decisions for me if (or because now) I cannot. (Or person provides reasons why they are not comfortable with it.)
Q10:	What happens if your illness gets worse and you are unable to speak for yourself?
A:	The person would make decisions for me.
Q11:	Who would you choose as your agent?
A:	[Specific to person] (Repeats Q4; examiner assess consistency.)