Fill Your 5 Wishes Document Template

Fill Your 5 Wishes Document Template

The Five Wishes Document is a unique form that allows individuals to express their personal, emotional, and spiritual needs alongside their medical wishes in the event of a serious illness. This living will empowers you to select a trusted person to make healthcare decisions on your behalf when you are unable to do so. By completing this straightforward document, you can ensure that your preferences are honored and that your loved ones are not left to guess what you truly want.

Ready to take control of your healthcare decisions? Fill out the Five Wishes Document by clicking the button below!

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Life is unpredictable, and when faced with serious illness, the decisions regarding medical care can become overwhelming for both patients and their families. The Five Wishes document serves as a vital tool that empowers individuals to articulate their healthcare preferences clearly. This form encompasses five key areas: designating a health care agent to make decisions when one is unable, specifying desired medical treatments, outlining comfort preferences, expressing how one wishes to be treated by others, and sharing important messages with loved ones. By filling out the Five Wishes document, individuals can ensure their values and wishes are honored, alleviating the burden on family members who might otherwise struggle to make difficult choices without guidance. Developed with input from legal experts and healthcare professionals, this living will goes beyond traditional advance directives by addressing emotional and spiritual needs alongside medical wishes. The straightforward format allows anyone aged 18 or older to complete it with ease, making it accessible to a broad audience. With over 19 million users and recognition from various healthcare and legal communities, Five Wishes stands out as a compassionate approach to advance care planning.

Documents used along the form

The Five Wishes document serves as a vital tool for individuals seeking to articulate their healthcare preferences and appoint a trusted person to make decisions on their behalf when they are unable to do so. To complement this document, several other forms and documents may be utilized to ensure comprehensive planning regarding health care and end-of-life decisions. Below is a list of these additional documents, each briefly described to provide clarity on their purpose and importance.

  • Living Will: A living will outlines a person's preferences regarding medical treatment in situations where they are unable to communicate their wishes, particularly in cases of terminal illness or irreversible conditions. It specifies the types of medical interventions a person desires or wishes to avoid.
  • Durable Power of Attorney for Health Care: This document designates a specific individual as an agent to make healthcare decisions on behalf of another person if they become incapacitated. It grants the agent the authority to make choices consistent with the individual's values and preferences.
  • Do Not Resuscitate (DNR) Order: A DNR order is a medical directive that indicates a person's wish not to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. This document must be signed by a physician and is typically placed in the patient's medical records.
  • Organ Donation Registration: This form allows individuals to express their wishes regarding organ donation after death. By registering, a person can ensure that their desire to donate organs is honored, providing a gift of life to others.
  • Civil Case Cover Sheet: This document is required for initiating a civil case in California, collecting essential information about the case type, parties involved, and the nature of the legal action. To complete it accurately, visit californiapdfforms.com/california-civil-form/ for more details.
  • Advance Directive: An advance directive is a legal document that encompasses both a living will and a durable power of attorney for health care. It provides comprehensive guidance on a person's healthcare preferences and designates an agent to make decisions if necessary.
  • Healthcare Proxy: Similar to a durable power of attorney, a healthcare proxy designates a person to make medical decisions on behalf of another individual. This document often includes specific instructions about the types of treatment the proxy should consider.
  • Patient Advocate Designation: This form allows individuals to appoint a patient advocate who will represent their interests in healthcare settings. The advocate's role is to ensure that the patient's wishes and preferences are communicated and respected by medical professionals.

Incorporating these documents alongside the Five Wishes form can provide a more holistic approach to healthcare planning. Each document plays a unique role in ensuring that individuals' preferences are honored, thus fostering peace of mind for both the individual and their loved ones during challenging times.

Document Preview Example

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,

 

 

WKH\ZRQ·WKDYHWRPDNHKDUGFKRLFHV

 

 

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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6RXWK'DNRWD

Arkansas

Kentucky

1HYDGDD

 

 

 

 

Tennessee

&DOLIRUQLD

/RXLVLDQD

1HZ-HUVH\

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vermont

 

 

&RORUDGR

Maine

1HZ0H[LFR

 

 

 

 

Virginia

 

 

&RQQHFWLFXW

Maryland

 

 

 

RUN

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

7HOO\RXU+HDOWK&DUH$JHQWIDPLO\

 

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

 

 

 

 

 

&KRRVHVRPHRQHZKRNQRZV\RXYHU\ZHOO

DQGIROORZ\RXUZLVKHV<RXU+HDOWK&DUH

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

YHG6RPHWLPHVWKH\are the

 

 

 

HPRWLRQDOO\LQYRO

 

 

 

 

 

owner or operator of a health or residential

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EHVWFKRLFH<RX

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,

 

 

 

 

 

 

 

 

 

 

 

SAMIDPLO\PHPEHURUIULHQGDV\RXU+HDOWK&DUH

‡

 

6HUYLQJDVDQDJHQWRUSUR[\IRURU

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

‡

6HH DQGDSSURYHUHOHDVHRIP\PHGLFDOUHFRUGV

 

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

 

JHWDQ\RIWKHVHILOHVP\+HDOW

 

$JHQWFDQ

 

 

K&DUH

 

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.

‡ /LVWHGEHORZDUHDQ\FKDQJHVDGGLWLRQVRU OLPLWDWLRQVRQP\+HDOWK&DUH$JHQW·VSRZHUV

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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

 

 

 

P\+HDOWK&DUH$JHQWOR

 

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

,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 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

WKH\GRQ·WDJUHHZLWKWKHP

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

WKHPMR\DQGQRWVRUURZ

After my death, I would like my body to

EHFLUFOHRQHEXULHGRUFUHPDWHG

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

OLVWPXVLFVRQJVUHDGLQJVRURWKHUVSHFLILFUHTXHVWVWKDW\RXKDYH

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(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:

 

 

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Witness Statement (2 witnesses needed):

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The individual appointed as (agent/proxy/

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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

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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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Guidelines on How to Fill Out 5 Wishes Document

Filling out the Five Wishes document is a straightforward process that allows you to express your healthcare preferences. This form is designed to help you communicate your wishes regarding medical treatment, comfort, and how you want to be treated if you become seriously ill. Once completed and signed, it will be valid in most states.

  1. Begin by printing your full name and birthdate at the top of the form.
  2. In the first section, identify the person you want to make healthcare decisions for you. Write their name, phone number, and address.
  3. If your first choice is unavailable, list your second and third choices for a healthcare agent, including their contact information.
  4. Next, indicate what medical treatments you want or do not want. Be clear about your preferences.
  5. Specify how comfortable you want to be during treatment. You can include details about pain management or other comfort measures.
  6. Describe how you want people to treat you. This may include emotional support or specific interactions you prefer.
  7. Write down any messages or wishes you want your loved ones to know. This can be anything important you want to share.
  8. Review the entire document to ensure all information is accurate and reflects your wishes.
  9. Sign and date the form at the designated area. Make sure to have a witness sign if required by your state.

Similar forms

The Five Wishes document shares similarities with an Advance Directive, which is a legal document that allows individuals to outline their preferences for medical treatment in case they become unable to communicate their wishes. Like Five Wishes, an Advance Directive can appoint a healthcare proxy, someone who will make decisions on behalf of the individual. Both documents aim to ensure that a person's healthcare preferences are honored, providing peace of mind to both the individual and their loved ones. However, Five Wishes goes a step further by addressing emotional, spiritual, and personal preferences, making it more comprehensive in its approach.

Another document that resembles Five Wishes is the Durable Power of Attorney for Healthcare. This document allows a person to designate someone else to make healthcare decisions on their behalf if they are incapacitated. Similar to Five Wishes, it emphasizes the importance of choosing a trusted individual for this role. However, while a Durable Power of Attorney primarily focuses on medical decisions, Five Wishes includes broader considerations, such as comfort and treatment preferences, allowing for a more holistic view of care.

When considering the procedures for vehicle-related legal matters, understanding the Texas Motor Vehicle Power of Attorney form is crucial. This form can particularly help those who are unable to manage their vehicle affairs, allowing someone else to act on their behalf. For more detailed guidance on this process, resources can be found at legalpdf.org.

The Living Will is another document that aligns closely with Five Wishes. A Living Will is a type of Advance Directive that specifically outlines what medical treatments a person does or does not want in situations where they cannot communicate. Like Five Wishes, it is designed to guide healthcare providers and loved ones in making decisions that reflect the individual's wishes. However, Five Wishes expands on this by incorporating personal and emotional aspects, making it a more personalized tool for end-of-life care.

Healthcare providers often utilize a Medical Order for Life-Sustaining Treatment (MOLST) form, which is similar in purpose to Five Wishes. The MOLST form provides specific medical orders regarding treatment preferences, particularly for patients with serious illnesses. Both documents aim to ensure that healthcare providers understand a patient's wishes. However, Five Wishes allows for a more narrative approach, encouraging discussions about values and preferences beyond just medical orders.

Lastly, the Physician Orders for Life-Sustaining Treatment (POLST) form is another document comparable to Five Wishes. The POLST form is designed for individuals with serious health conditions and outlines specific medical treatments they wish to receive or avoid. Like Five Wishes, it is intended to be a clear guide for healthcare providers. However, Five Wishes emphasizes personal values and the quality of life, making it more comprehensive in addressing the emotional and spiritual needs of individuals facing serious health challenges.

Consider Common Documents

Misconceptions

1. Five Wishes is only for older adults. Many people believe that Five Wishes is only relevant for seniors. In reality, anyone aged 18 or older can benefit from this document. It's never too early to express your wishes.

2. Five Wishes is a legally binding document everywhere. While Five Wishes is valid in many states, it may not meet the legal requirements in every state. Always check your local laws to ensure it’s recognized where you live.

3. Filling out Five Wishes is complicated. Some think that completing the Five Wishes document is a daunting task. In truth, it’s designed to be straightforward. You simply check boxes, circle options, or write a few sentences to express your preferences.

4. Five Wishes only covers medical decisions. Many people assume that Five Wishes is limited to medical choices. However, it also addresses emotional and spiritual needs, making it a holistic approach to end-of-life care.

5. You can't change your mind once you complete Five Wishes. Some individuals feel locked into their choices after filling out the form. If you change your mind, you can revoke your previous wishes and create a new document at any time.

6. Your family can’t discuss your wishes without Five Wishes. There’s a misconception that if you don’t have Five Wishes, your family can’t talk about your healthcare preferences. In reality, open conversations about your wishes are always encouraged, with or without a formal document.

7. Five Wishes is just like a traditional living will. While Five Wishes serves as a living will, it goes beyond medical directives. It emphasizes personal values and how you want to be treated, making it unique and more comprehensive.

8. Once you complete Five Wishes, you don’t need to inform anyone. Some people think that filling out the document is enough. It’s essential to share your completed Five Wishes with your healthcare agent, family, and doctor to ensure everyone understands your preferences.

File Features

Fact Name Details
Document Purpose The Five Wishes document allows individuals to express their preferences for medical treatment and personal care in the event they cannot communicate their wishes due to illness.
Living Will Five Wishes is recognized as the first living will that addresses not only medical wishes but also emotional and spiritual needs.
Health Care Agent The form allows individuals to designate a Health Care Agent, who will make medical decisions on their behalf if they are unable to do so.
Ease of Use Completing the Five Wishes document is straightforward; individuals can check boxes, circle options, or write brief notes to express their preferences.
State Validity Five Wishes is valid in 42 states and the District of Columbia, provided it meets the specific legal requirements of each state.
Governing Laws In states like Florida, Five Wishes complies with state laws regarding advance directives, ensuring it is a legally recognized document.
Widespread Adoption Over 19 million people have utilized Five Wishes, making it a widely accepted tool for end-of-life planning.
Family Communication The document facilitates important discussions among family members about health care preferences, reducing the burden of decision-making during crises.
Changing Wishes If an individual wishes to change their designated Health Care Agent or any other preferences, they can do so by filling out a new Five Wishes document.
Language Accessibility Five Wishes is available in 27 languages, making it accessible to a diverse population and ensuring that more individuals can express their health care wishes.