Additional Considerations

Your personal feelings are just as important as the medical facts. You can use the following section to think about what else matters to you in this decision, and record how you feel about the following statements.

1. Are there other important factors to consider?(example: important milestones, spiritual or cultural beliefs)

2. Do you feel you know enough about your options?

My Reasons for Conservative Care
My Reasons for Dialysis

3. Which option do you think you would prefer? (5-Definitely CKM | 4-Probably CKM | 3-Unsure | 2-Probably Dialysis | 1-Definitely Dialysis)

4. Do you want others to be involved in this decision? If so:

5. I’m ready to take action

6. I want to learn more about my options

7. Use the following space to list questions, concerns and next steps: