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Nursing Home Resident Advance Directive: Clinical
Scenario Questionnaire

Verbal Instructions: This questionnaire will provide some examples of common things that people face in nursing homes. After I describe what might happen I will ask you about five possible choices of treatments you would or would not want if you were faced with the illness described.

Before I ask you what treatments you would or would not want, it is important for you to understand what is involved with each treatment (use informational reference sheets).

If the resident responds yes: How many times would you estimate that you have been presented with information about such treatments?

For all scenarios, imagine that you are in your current state of health.

Scenario 1

One day you begin to develop fever and shortness of breath. Your doctor prescribes medication but you continue to have fever and shortness of breath. In the event that this illness progresses within the next several hours, which of the following treatments would you choose? Remember that you can choose all or none of the options:

  1. Physician Visitation in the Nursing Facility Rather than an Emergency Room Visit
  2. Hospitalization
  3. Cardiopulmonary resuscitation
  4. Mechanical Breathing
  5. Artificial hydration/nutrition
  6. Comfort/Hospice Care

Scenario 2

One morning you wake up and notice that you are unable to speak. When you try to get out of bed you notice that you are also unable to move your left side. You conclude that you may have had a stroke during the night. In the event that this stroke progresses within the next several hours which of the following treatments would you choose? Remember that you can choose all or none of the options:

  1. Physician Visitation in the Nursing Facility Rather than an Emergency Room Visit
  2. Hospitalization
  3. Cardiopulmonary resuscitation
  4. Mechanical Breathing
  5. Artificial hydration/nutrition
  6. Comfort/Hospice Care

Scenario 3

One afternoon you develop confusion and the nurses find you wandering down out of the nursing home. The nurse thinks you may be confused because you have developed an infection. In the event that this confusion progresses within the next several hours which of the following treatments would you choose? Remember that you can choose all or none of the options:

  1. Physician Visitation in the Nursing Facility Rather than an Emergency Room Visit
  2. Hospitalization
  3. Cardiopulmonary resuscitation
  4. Mechanical Breathing
  5. Artificial hydration/nutrition
  6. Comfort/Hospice Care

Scenario 4

As you walk back from the dining room one evening, you catch your foot on the floor and fall. You notice pain in your hip and suspect your hip may be broken. In the event that your pain progresses within the next several hours which of the following treatments would you choose? Remember that you can choose all or none of the options:

  1. Physician Visitation in the Nursing Facility Rather than an Emergency Room Visit
  2. Hospitalization
  3. Cardiopulmonary resuscitation
  4. Mechanical Breathing
  5. Artificial hydration/nutrition
  6. Comfort/Hospice Care

Scenario 5

After the nurse takes your vital signs one day she explains that your readings are much higher than usual. You do not feel sick or uncomfortable. In the event that your abnormal vital signs worsen within the next several hours which of the following treatments would you choose? Remember that you can choose all or none of the options:

  1. Physician Visitation in the Nursing Facility Rather than an Emergency Room Visit
  2. Hospitalization
  3. Cardiopulmonary resuscitation
  4. Mechanical Breathing
  5. Artificial hydration/nutrition
  6. Comfort/Hospice Care