5 Wishes Document Form

5 Wishes Document Form

The Five Wishes Document is a unique form that allows individuals to express their personal, emotional, and spiritual needs regarding medical care in the event they are unable to communicate those wishes themselves. This living will empowers you to designate a trusted person to make health care decisions on your behalf and outlines your preferences for treatment and comfort. By completing this straightforward document, you can ensure your loved ones understand your desires during challenging times.

Access 5 Wishes Document Here

Life is full of uncertainties, and when it comes to health care decisions, having a plan can provide peace of mind. The Five Wishes document is designed to help individuals express their preferences for medical treatment and care in a straightforward manner. This form allows you to designate a trusted person to make health care decisions on your behalf if you become unable to do so. It goes beyond the typical living will by addressing not just medical choices but also your personal, emotional, and spiritual needs. With Five Wishes, you can outline the kind of medical treatment you desire or wish to avoid, specify how comfortable you want to be during care, and express how you want to be treated by those around you. Furthermore, it offers a space for you to share important messages with your loved ones, ensuring they understand your wishes during challenging times. Valid in most states, this easy-to-use document empowers individuals to take control of their health care decisions, fostering open conversations among family members and caregivers about what truly matters when facing serious illness.

Common Questions

What is the Five Wishes document?

The Five Wishes document is a unique form that allows individuals to express their personal, emotional, and spiritual needs regarding medical treatment and care. It serves as a living will, enabling you to designate someone to make health care decisions on your behalf if you are unable to do so. This document empowers you to communicate your wishes about how you want to be treated in the event of a serious illness.

Who should consider using Five Wishes?

Five Wishes is designed for anyone aged 18 or older, regardless of marital status or family situation. This includes single individuals, married couples, parents, adult children, and friends. More than 19 million people have utilized this document, making it a popular choice among various groups, including healthcare providers, faith communities, and employers.

How does Five Wishes benefit my family?

By completing the Five Wishes document, you provide clarity for your family during difficult times. It eliminates the guesswork about your preferences, allowing your loved ones to make informed decisions that align with your wishes. This can significantly ease the emotional burden on family members, ensuring they can support you in the way you desire if you become seriously ill.

What happens if I already have a living will?

If you currently have a living will or a durable power of attorney for health care and wish to switch to Five Wishes, you can do so easily. Simply fill out and sign the Five Wishes document. Once signed, it revokes any previous advance directives. Be sure to destroy old copies or mark them as "revoked" to avoid confusion.

Is Five Wishes legally valid in all states?

Five Wishes is legally recognized in the District of Columbia and 42 states across the U.S. However, if you live in a state not listed, the document may not meet specific legal requirements. Despite this, many people from non-listed states still find value in using Five Wishes alongside their state's legal forms, as it provides a comprehensive guide for family and healthcare providers.

How do I choose my Health Care Agent?

Choosing the right person to be your Health Care Agent is crucial. This individual should be someone who knows you well, understands your wishes, and is willing to advocate for you. Ideally, they should be at least 18 years old and not be your healthcare provider or an employee of a facility where you receive care. Discussing your wishes with them beforehand ensures they are prepared to make decisions that reflect your values.

Can I change my mind after designating a Health Care Agent?

Yes, you can change your mind about your Health Care Agent at any time. To do this, you must destroy all copies of the Five Wishes document that includes your previous agent's name. You can also write "Revoked" across the name of the agent you wish to cancel. It's essential to inform your family and healthcare provider about any changes to ensure they are aware of your current wishes.

Key takeaways

Here are key takeaways regarding the completion and utilization of the Five Wishes Document form:

  • Control Over Medical Decisions: The Five Wishes document allows individuals to specify their preferences for medical treatment and care if they become seriously ill.
  • Designating a Health Care Agent: The form enables users to choose a trusted person to make health care decisions on their behalf when they are unable to do so.
  • Comprehensive Coverage: It addresses not only medical wishes but also personal, emotional, and spiritual needs, providing a holistic approach to end-of-life care.
  • Easy to Complete: The form is user-friendly, requiring simple checks, circles, or brief written statements to convey wishes.
  • Legal Validity: Once signed, the document is valid in most states, ensuring that the wishes expressed are respected by health care providers.
  • Facilitating Family Conversations: Completing Five Wishes encourages discussions among family members, reducing the burden of decision-making during difficult times.
  • Revocation of Previous Directives: If a new Five Wishes document is filled out, it automatically revokes any prior living wills or health care directives.
  • Wide Accessibility: The Five Wishes document is available to anyone aged 18 or older, making it a valuable resource for a diverse range of individuals and families.

Form Properties

Fact Name Description
Purpose The Five Wishes document allows individuals to express their medical, emotional, and spiritual preferences for healthcare in case they become seriously ill.
Legal Validity Once properly filled out and signed, Five Wishes is valid under the laws of most states, including the District of Columbia and 42 other states.
Who Can Use It Any individual aged 18 or older can use Five Wishes, regardless of marital status or family situation. Over 19 million people have utilized this document.
How to Change To adopt Five Wishes, individuals must fill out and sign the form, revoking any previous advance directives. It is essential to inform relevant parties about the new document.

Misconceptions

Here are five common misconceptions about the Five Wishes document:

  • It is only for older adults. Many people believe that Five Wishes is only for seniors. In reality, it is designed for anyone aged 18 and older, regardless of their health status.
  • Five Wishes is not legally binding. Some think that this document lacks legal weight. However, when properly completed and signed, it is valid in most states and can guide healthcare decisions.
  • It only addresses medical decisions. While Five Wishes does cover medical treatment preferences, it also encompasses emotional, personal, and spiritual wishes, making it a comprehensive tool for end-of-life planning.
  • Once completed, it cannot be changed. Many assume that the document is permanent. In fact, individuals can revoke or modify their Five Wishes at any time by following specific procedures.
  • Healthcare providers will ignore it if it is not a formal living will. Some believe that without a traditional living will, their wishes will be disregarded. However, healthcare professionals are generally obligated to respect a patient's wishes, regardless of the format.

5 Wishes Document Preview

FIVE

WISH S®

M Y W I S H F O R :

The Person I Want too Make Car1e Decisions for Me When I Can’t

The Kind of Medical Treat2ment I Want or Don’t Want

How Comfortable3 I Want to Be

How I Want People4 to Treat Me

What I Want My Loved5 Ones to Know

print your name

birthdate

Five Wishes

There are many things in life that are out of our hands. This Five Wishes document gives you a way to control somethingg very

important—how you are treated if you get seriously ill. It is ann easy-to- complete form that lets you say exactly what you want. Once it is filled out and properly signed it is valid under the laws off most states.

What Is Five Wishes?

Five Wishes is the first living will that talks about your personal, emotional and spiritual needs as well as your medical wishes. It lets you choose the person you want to make health care decisions for you if you are not able to make them for yourselff. Five Wishes

lets you say exactly how you wish to be

treated if you get seriously ill. It was written with the help of The American Bar

$VVRFLDWLRQ·V&RPPLVVLRQRQ/DZDQG$JLQJ DQGWKHQDWLRQ·VOHDGLQJH[SHUWVLQHQGRIOLIH FDUH,W·VDOVRHDV\WRXVH$OO\RXKDYHWRGRLV check a box, circle a direction, or write a few

sentences.

How Five Wishes Can Help You And Your Family

It lets

you talk with your family,

 

 

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frie

 

 

 

 

 

 

 

 

 

without knowing your wishes.

 

 

nds and doctor about how you

 

 

wantt

 

 

 

 

 

 

 

 

 

 

to be treated if you become

• You can know what your mom, dad,

 

 

seriou

 

 

 

 

 

 

 

 

 

sly ill.

 

 

 

 

spouse, or friend wants. You can be

 

Your family membe

rs will not have to

 

there for them when they need you

 

 

 

 

 

t. It protects them

most. You will understand what they

 

 

guess what you wan

 

 

 

ously ill, because

really want.

 

 

if you become seri

How Five Wishes Began

For 12 years, Jim Towey worked closely with Mother Teresa, and, for one year, he lived in a KRVSLFHVKHUDQLQ:DVKLQJWRQ'&,QVSLUHGE\ WKLVILUVWKDQGH[SHULHQFH0U7RZH\VRXJKWD way for patients and their families to plan ahead and to cope with serious illness. The result is

2Five Wishes and the response to it has been

RYHUZKHOPLQJ,WKDVEHHQIHDWXUHGRQ&11 DQG1%&·V7RGD\6KRZDQGLQWKHSDJHVRI Time and MoneyPDJD]LQHV1HZVSDSHUVKDYH called Five Wishes the first “living will with a heart and soul.” Today, Five Wishes is available in 27 languages.

Who Should Use Five Wishes

Five Wishes is for anyone 18 or older — married, single, parents, adult children, and friends. More than 19 million people of all ages have already used it. Because it

works so well, lawyers, doctors, hospitals and hospices, faith communities, employers, and retiree groups are handing outt this document.

Five Wishes States

If you live in the District of Columbia or one of the 42 states listed below, youu can use )LYH:LVKHVDQGKDYHWKHSHDFHRIPLQGWRNQRZWKDWLWVXEVWDQWLDOO\PHHWV\RXUVWDWH·V requirements under the law:

Alaska

Illinois

Montana

 

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Arizona

Iowa

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Arkansas

Kentucky

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Tennessee

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1HZ-HUVH\

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vermont

 

 

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Maine

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Virginia

 

 

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Maryland

 

 

 

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Washington

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Delaware

Massachusetts

 

 

 

 

 

 

 

 

 

West Virginia

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Florida

Michigan

 

 

 

 

 

 

 

Wisconsin

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Georgia

Minnesota

Oklahoma

 

 

 

Wyoming

Hawaii

Mississippi

 

 

 

 

 

 

 

 

 

 

 

 

Pennsylvania

 

 

 

 

 

Idaho

Missouri

 

 

 

 

 

 

 

 

Rhode Island

 

 

 

 

 

If your state is not one of the 42 states listed here, Five Wishes does not meet the technical UHTXLUHPHQWVLQWKHVWDWXWHVRI\RXUVWDWH6RVRPHGRFWRUVLQ\RXUVWDWHPD\EHUHOXFWDQW to honor Five Wishes. However, many people from states not on this list do complete Five :LVKHVDORQJZLWKWKHLUVWDWH·VOHJDOIRUP7KH\ILQGWKDW)LYH:LVKHVKHOSVWKHPH[SUHVV all that they want and provides a helpful guide to family members, friends, care givers and doctors. Most doctors and health care professionals know they need to listen to your wishes no matter how you express them.

How Do I Change To Five Wishes?

You may already have a living will or a durable power of attorney for health care. If you want to use Five Wishes instead, all you need to do is fill out and sign a new Five Wishes as directed. As soon as you sign it, it takes away any advance directive you had before. To make sure the right form is used, please do the following:

D

estroy all copies of your old living will

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or durable power of attorney for health

 

members, and doctor that you have

 

care. Or you can write “revoked” in large

 

filled out a new Five Wishes.

 

letters across the copy you have. Tell

 

Make sure they know about your

 

your lawyer if he or she helped prepare

 

new wishes.

 

those old forms for you. AND

 

 

3

WISH 1

The Person I Want To Make Health Care Decisions For Me

When I Can’t Make Them For Myself.

f I am no longer able to make my own health care

 

 

 

• My attending or treating doctor finds I am no

I decisions, this form names the person I choose to

 

 

 

 

longer able to make health ca

 

es, AND

 

 

 

 

re choic

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

make these choices for me. This person will be my

 

 

 

• Another health care profe

ssional agrees

t

hat

Health Care Agent (or other term that may be used in

 

 

 

 

this is true.

 

 

 

 

 

 

 

 

 

 

MPLE

my state, such as proxy, representative, or surrogate).

 

 

If my state has a different

 

w

ay of finding that I am not

 

This person will make my health care choices if both

 

 

able to make health c

 

are choices, then my state’s way

 

of these things happen:

 

 

 

should be followe

d.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Person I Choose As My Health Care Agent Is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Choice Name

 

 

Ph

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

one

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

If this person is not able or willing to make thesee choices for me, OR is divorced or legally separated from me, OR this person has died, then these people aree my next choices:

Second Choice Name

 

 

 

 

 

e

 

Third Choice Nam

 

 

 

 

 

 

 

 

Address

 

A

 

 

 

 

 

 

ddress

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Picking The R

 

Your Health Care Agent

 

ight Person To Be

 

 

 

 

 

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can make difficult

Agent should be at least 18 years or older (in

cares about you, and who

 

 

 

 

 

 

 

ily member may

&RORUDGR\HDUVRUROGHUDQGVKRXOGnot be:

decisions. A spouse or fam

 

not be the best choice because they are too

 

 

Your health care provider, including the

 

 

 

 

 

 

 

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owner or operator of a health or residential

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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NQRZEHVW&KRRVHVRPHRQH

 

 

 

 

 

 

 

 

 

or community care facility serving you.

w

ho is able to stand up for you so that your

 

 

 

 

 

 

 

 

 

 

 

 

wishes are followed. Also, choose someone who

 

 

An employee or spouse of an employee of

is likely to be nearby so that they can help when

 

 

 

 

your health care provider.

you need them. Whether you choose a spouse,

 

 

 

 

 

 

 

 

 

 

 

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Agent, make sure you talk about these wishes

 

 

 

 

more people unless he or she is your

and be sure that this person agrees to respect

 

 

 

 

spouse or close relative.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

I understand that my Health Care Agent can make health care decisions for me. I want my Agent to be able to do the

following: (Please cross out anything you don’t want your Agent to do that is listed below.)

Make choices for me about my medical care

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or services, like tests, medicine, or surgery.

 

and personal files. If I need to sign my name to

 

This care or service could be to find out what my

 

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health problem is, or how to treat it. It can also

 

sign it for me.

 

include care to keep me alive. If the treatment or

Move me to another

 

 

 

 

 

FDUHKDVDOUHDG\VWDUWHGP\+HDOWK&DUHAgent

state to get the care I need

 

 

 

or to carry out m

y wishes.

 

can keep it going or have it stopped.

 

 

 

 

 

 

 

 

 

Interpret any instructions I have given in

this form or given in other discussions, according

WRP\+HDOWK&DUH$JHQW·VXQGHUVWDQGLQJRIP\ wishes and values.

‡ &RQVHQWWRDGPLVVLRQWRDQDVVLVWHGOLYLQJIDFLOLW\ hospital, hospice, or nursing home for me. My +HDOWK&DUH$JHQWFDQKLUHDQ\NLQGRIKHDOWK care worker I may need to help me or take care of me. My Agent may also fire a health care worker, if needed.

Make the decision to request, take away or not

JLYHPHGLFDOWUHDWPHQWVLQFOXGLQJDUWLILFLDOO\ provided food and water, andd any other treatments to keepp me alive.

Authorize or refuse to authorize any medication or procedure needed to help with pain.

Take any legal action needed to carry out my wishes.

Donate useable organs or tissues of mine as allowed by law.

• Apply for Medicare, Medicaid, or other programs RULQVXUDQFHEHQHILWVIRUPH0\+HDOWK&DUH Agent can see my personal files, like bank records, to find out what is needed to fill out these forms.

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______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If I Change My Mind About Having A Health Care Agent, I Will

Destroy all copies of this part of the

• Write the word “Revoked” in large

 

Five Wishes form. OR

letters across the name of each agent

• Tell someone, such as my doctor or

whose authority I want to cancel.

6LJQP\QDPHRQWKDWSDJH

 

family, that I want to cancel or change

 

 

 

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5

WISH 2

My Wish For The Kind Of Medical Treatment

I Want Or Don’t Want.

I b elieve that my life is precious and I deserve to be treated with dignity. When the timee comes that

I am very sick and am not able to speak for myself, I want the following wishes, and any other directions I have given to my Health Care Agent, to be respected and followed.

What You Should Keep In Mind As My Caregiver

I do not want to be in pain. I want my doctor to give me enough medicine to relieve my pain, even if that means that I will be drowsy or sleep more than I would otherwise.

I do nott want anything done or omitted by my doctors or nurses with the intention of taking my life.

I want to be offered food and fluids by mouth, and kept clean and warm.

What “Life-Support Treatment” Means To Me

/LIHVXSSRUWWUHDWPHQWPHDQVDQ\PHGLFDOSURFH dure, device or medication to keep me alive.

/LIHVXSSRUWWUHDWPHQWLQFOXGHVPHGLFDO devices put in me to help me breathe; food and ZDWHUVXSSOLHGE\PHGLFDOGHYLFHWXEHIHHGLQJ FDUGLRSXOPRQDU\UHVXVFLWDWLRQ&35PDMRU surgery; blood transfusions; dialysis; antibiotics;

and anything else meant to keep me alive.

,I,ZLVKWROLPLWWKHPHDQLQJRIOLIHVXSSRUW treatment because of my religious or personal beliefs, I write this limitation in the space below. I do this to make very clear what I want and under what conditions.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

In Case Of An Emergency

Iff you have a medical emergency and ambulance personnel arrive, they may look to see if you have a Do Not Resuscitate form or bracelet. Many states require a person to have a Do Not Resuscitate form filled out and

signed by a doctor. This form lets ambulance SHUVRQQHONQRZWKDW\RXGRQ·WZDQWWKHPWRXVH OLIHVXSSRUWWUHDWPHQWZKHQ\RXDUHG\LQJ3OHDVH check with your doctor to see if you need to have a Do Not Resuscitate form filled out.

6

Here is the kind of medical treatment that I want or don’t want in the four situations listed below. I want my Health Care Agent, my family, my doctors and other health care providers, my friends and all others to know these directions.

Close to death:

If my doctor and another health care professional both decide that I am likely to die within a short period of WLPHDQGOLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKH PRPHQWRIP\GHDWK&KRRVHoneRIWKHIROORZLQJ

,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

, GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.

,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to

VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.

In A Coma And Not Expected Too Wake Up Or Recover:

If my doctor and another health care professional both decide that I am in a coma from which I am not expected WRZDNHXSRUUHFRYHUDQG,KDYHEUDLQGDPDJHDQGOLIH support treatment would only delay the moment of my GHDWK&KRRVHoneRIWKHIROORZLQJ

,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

, GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.

,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to

VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.

Permanent And Severe Brain Damage And Not Expected To Recover:

If my doctor and another health care professional both decide that I have permanentt and severe brain damage,

(for example, I can open myy eyes, but I can not speak RUXQGHUVWDQGDQG,DPQRWH[SHFWHGWRJHWEHWWHUDQG OLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKHPRPHQWRI P\GHDWK&KRRVHoneRIWKHIROORZLQJ

,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

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VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.

In Another Condition Under Which I Do Not Wish To Be Kept Alive:

If there is another condition under which I do not wish WRKDYHOLIHVXSSRUWWUHDWPHQW,GHVFULEHLWEHORZ,Q this condition, I believe that the costs and burdens of

OLIHVXSSRUWWUHDWPHQWDUHWRRPXFKDQGQRWZRUWKWKH benefits to me. Therefore, in this condition, I do not want OLIHVXSSRUWWUHDWPHQW)RUH[DPSOH\RXPD\ZULWH ´HQGVWDJHFRQGLWLRQµ7KDWPHDQVWKDW\RXUKHDOWKKDV gotten worse. You are not able to take care of yourself in DQ\ZD\PHQWDOO\RUSK\VLFDOO\/LIHVXSSRUWWUHDWPHQW will not help you recover. Please leave the space blank if \RXKDYHQRRWKHUFRQGLWLRQWRGHVFULEH

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

7

Th e next three wishes deal with my personal, spiritual and emotional wishes. They are important to me. I want to be treated with dignity near the end of my life, so I would like people to do the things

written in Wishes 3, 4, and 5 when they can be done. I understand that my family, my doctors and other health care providers, my friends, and others may not be able to do these things or are not required by law to do these things. I do not expect the following wishes to place new or added legal duties on my doctors or other health care providers. I also do not expect these wishes to excuse my doctor or other health care providers from giving mee the proper care asked for by law.

WISH 3

My Wish For How Comfortable I Want To Bee.

(Please cross out anything that you don’t agree with.)

I do not want to be in pain. I want my doctor to give me enough medicine to relieve my pain, even if that means I will be drowsy or sleep more than I would otherwise.

If I show signs of depression, nausea, shortness of breath, or hallucinations, I want my care givers to do whatever they can to help me.

I wish to have a cool moist cloth put onn my head if I have a fever.

I want my lips and mouth kept moist to stop dryness.

I wish to have warm baths often. I wish to be kept fresh and clean at all times.

I wishh to be massaged with warm oils as often as I can be.

I wish to have my favorite music played when possible until my time of death.

I wish to have personal care like shaving, nail clipping, hair brushing, and teeth brushing, as long as they do not cause me pain or discomfort.

‡ ,ZLVKWRKDYHUHOLJLRXVUHDGLQJVDQGZHOO loved poems read aloud when I am near death.

I wish to know about options for hospice care to provide medical, emotional and spiritual care for me and my loved ones.

WISH 4

My Wish For How I Want People To Treat Me.

(Please cross out anything that you don’t agree with.)

I wish to have people with me when possible. I want someone to be with me when it seems that death may come at any time.

I wish to have my hand held and to be talked

WRZKHQSRVVLEOHHYHQLI,GRQ·WVHHPWR respond to the voice or touch of others.

I wish to have others by my side praying for me when possible.

I wish to have the members of my faith community told that I am sick and asked to pray for me and visit me.

I wish to be cared for with kindness and cheerfulness, and not sadness.

I wish to have pictures of my loved ones in my room, near my bed.

If I am not able to control my bowel or bladder functions, I wish for my clothes and bed linens to be kept clean, and for them to be changed as soon as they can be if they have been soiled.

I want to die in my home, if that can be done.

8

WISH 5

My Wish For What I Want My Loved Ones To Know.

(Please cross out anything that you don’t agree with.)

I wish to have my family and friends know that I love them.

I wish to be forgiven for the times I have hurt my family, friends, and others.

I wish to have my family, friends and others know that I forgive them for when they may have hurt me in my life.

I wish for my family and friends to know that I do not fear death itself. I think it is not the end, but a new beginning for me.

I wish for all of my family members to make peace with each other before my death, if they can.

I wish for my family and friends to think about what I was like before I became seriously ill. I want them too remember me in this way after my death.

I wish for my family and friends and caregivers to respect my wishes even if

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I wish for my family and friends to look at my dying as a time of personal growth for everyone, including me. This will help me livee a meaningful life in my final days.

I wish for my family and friends to get counseling if they have trouble with my death. I want memories of my life to give

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After my death, I would like my body to

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My body or remains should be put in the

 

following

location

.

The following person knows my funeral

wishes:.

If anyone asks how I want to be remembered, please say the following about me:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

If there is to bee a memorial service for me, I wish for this service to include the following

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_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(Please use the space below for any other wishes. For example, you may want to donate any or all parts of your body when you die. You may also wish to designate a charity to receive memorial contributions. Please attach a VH DUDWHVKHHWRI D HULI\RXQHHGPRUHVSDFH

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

9

Signing The Five Wishes Form

Please make sure you sign your Five Wishes form in the presence of the two witnesses.

I, _________________________________, ask that my family, my doctors, and other health care providers,

P\IULHQGVDQGDOORWKHUVIROORZP\ZLVKHVDVFRPPXQLFDWHGE\P\+HDOWK&DUH$JHQWLI,KDYHRQHDQGKH RUVKHLVDYDLODEOHRUDVRWKHUZLVHH[SUHVVHGLQWKLVIRUP7KLVIRUPEHFRPHVYDOLGZKHQ,DPXQDEOHWRPDNH decisions or speak for myself. If any part of this form cannot be legally followed, I ask that all other parts of this form be followed. I also revoke any health care advance directives I have made before.

Signature:

 

 

___

Address:

 

 

 

 

 

 

Phone:

Date:

 

 

__

Witness Statement (2 witnesses needed):

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The individual appointed as (agent/proxy/

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7KHSHUVRQ·VKHDOWKFDUHSURYLGHULQFOXGLQJ RZQHURURSHUDWRURIDKHDOWKORQJWHUPFDUH or other residential or community care facility serving the person,

$QHPSOR\HHRIWKHSHUVRQ·VKHDOWKFDUH provider,

)LQDQFLDOO\UHVSRQVLEOHIRUWKHSHUVRQ·V health care,

An employee of a life or health insurance provider for the person,

Related to the person by blood, marriage, or adoption, and,

To the best of my knowledge, a creditor of the person or entitled to any part of his/her estate under a will or codicil, by operation of law.

(Some states may have fewer rules about who may be a witness. Unless you know your state’s rules, please follow the above.)

 

 

 

 

 

 

 

 

 

Signature of Witness

 

 

 

 

Signature of Witness #2

#1

 

 

 

 

 

 

 

 

 

 

Printed Name of Witn

 

 

 

 

 

Printed Name of Witness

ess

 

 

 

 

 

 

 

 

 

 

Address

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

Phone

 

 

NotarizationOnly required for residents of Missouri, North Carolina, South Carolina and West Virginia

If you live in Missouri, only your signature should be notarized.

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10

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Check out Other PDFs

Common mistakes

  1. Not Choosing the Right Health Care Agent: People often select a family member or friend without considering their ability to make tough decisions. It's crucial to choose someone who understands your wishes and can advocate for you.

  2. Leaving Sections Blank: Some individuals skip filling out certain parts of the form. Every section should be completed to ensure that your wishes are clear and that the document is legally valid.

  3. Not Discussing Wishes: Failing to talk about your wishes with your chosen health care agent and family can lead to confusion. Open communication is key to ensuring that everyone understands your preferences.

  4. Ignoring State Requirements: Each state has specific laws regarding living wills and health care directives. Not verifying that the Five Wishes document meets your state’s requirements can render it invalid.

Dos and Don'ts

When filling out the Five Wishes Document form, consider the following do's and don'ts:

  • Do read the entire document carefully before starting.
  • Do choose a health care agent who knows you well and respects your wishes.
  • Don't rush through the form; take your time to ensure clarity and accuracy.
  • Don't leave any sections blank; complete all required information to avoid confusion later.

Similar forms

The Advance Directive is a legal document that outlines an individual’s preferences for medical treatment in the event that they become unable to communicate their wishes. Similar to the Five Wishes document, it designates a health care proxy, allowing someone to make decisions on behalf of the patient. The Advance Directive is often more focused on medical procedures and interventions, while Five Wishes encompasses emotional, spiritual, and personal considerations as well. Both documents empower individuals to express their desires regarding end-of-life care, ensuring that their values and preferences are respected even when they cannot voice them directly.

The Durable Power of Attorney for Health Care is another document that shares similarities with the Five Wishes form. This legal instrument allows an individual to appoint someone to make health care decisions on their behalf if they are incapacitated. Like Five Wishes, it emphasizes the importance of having a trusted person in charge of health-related decisions. However, while the Durable Power of Attorney primarily focuses on the authority granted to the appointed individual, Five Wishes goes further by detailing the specific types of care and treatment the individual desires or wishes to avoid, thus providing a more comprehensive view of the person’s health care preferences.

The Living Will is a document that explicitly states an individual’s wishes regarding medical treatment in situations where they are unable to communicate their preferences. It is similar to the Five Wishes document in that both aim to guide health care providers and loved ones in making decisions that align with the individual’s desires. However, the Living Will typically addresses only medical interventions, such as resuscitation and life support, without delving into personal or emotional wishes. In contrast, Five Wishes offers a broader perspective, incorporating aspects like comfort and treatment by loved ones, which can be crucial in ensuring a dignified end-of-life experience.

Understanding legal documents is crucial for financial transactions, and for those in Nevada, utilizing a Promissory Note is a key step in formalizing a loan agreement. This document clearly records the terms of the debt, including repayment schedules and interest rates, thereby helping to prevent misunderstandings between parties involved in the transaction.

The Health Care Proxy is a document that allows individuals to appoint someone to make medical decisions on their behalf. It is akin to the Five Wishes document in that it emphasizes the importance of having a trusted person who understands the individual’s values and preferences. While both documents serve to ensure that a person’s wishes are honored, the Health Care Proxy is more focused on the legal authority granted to the appointed individual. Five Wishes, on the other hand, provides a more holistic approach by allowing individuals to articulate their desires for treatment, comfort, and the manner in which they wish to be cared for.

The Do Not Resuscitate (DNR) order is a specific type of advance directive that instructs medical personnel not to perform CPR or other resuscitation efforts if a patient’s heart stops or they stop breathing. Similar to the Five Wishes document, a DNR order reflects an individual’s preferences regarding medical intervention. However, while Five Wishes encompasses a broader range of wishes, including emotional and personal considerations, a DNR is narrowly focused on resuscitation efforts. Both documents are essential for ensuring that individuals receive care that aligns with their values and desires during critical health situations.