5 Wishes Document PDF Details

Contemplating the end of one’s life and making decisions about healthcare can be daunting. The Five Wishes document provides a unique solution, empowering individuals to articulate their preferences regarding medical treatment, comfort, personal relations, and final messages to loved ones in situations where they are unable to speak for themselves. Originating from a compassionate desire to blend medical, personal, emotional, and spiritual needs into end-of-life planning, this document bridges the gap between legal formality and human emotion. It achieves this by allowing individuals to appoint a healthcare agent, specify their medical treatment preferences, express their desires for comfort and how they wish to be treated by others, and share any important messages with their family and friends. Recognized and respected across most states, the Five Wishes document is crafted to be straightforward, requiring only simple steps to complete: checking boxes, circling options, or adding short narrative responses. Its legal validity in 42 states plus the District of Columbia offers a sense of security and peace of mind that one's personal directives will be honored. Additionally, for those who might already have existing legal directives such as a living will or a durable power of attorney for healthcare, transitioning to the Five Wishes document is seamless, effectively replacing previous directives upon completion and notification to relevant parties. This document not only facilitates meaningful conversations among family members and healthcare providers but also ensures that the wishes of the individual are known and respected, alleviating the burden of decision-making from loved ones during challenging times.

QuestionAnswer
Form Name5 Wishes Document
Form Length12 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min
Other namesfive wishes download, printable five wishes pdf, 5 wishes pdf, five wishes document pdf

Form 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,

 

 

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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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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

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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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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

 

 

 

 

 

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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

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Step 1: Hit the orange "Get Form Now" button on the following website page.

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The PDF file you decide to create will include the following areas:

portion of empty spaces in five wishes download

Make sure you fill in the of all ages have already used it, Five Wishes States, If you live in the District of, Alaska Arizona Arkansas, Illinois Iowa Kentucky, Montana cidcidcidcidcidcidcidcid, document, P L E, Wishes However many people from s, e of the states listed here Five, If your state is not one of the, and A S A space with the necessary information.

stage 2 to finishing five wishes download

You'll need to include some particulars in the box If this person is not able or, e choices for me OROR is divorced, Second Choice Name, Third Choice Nam Third Choice Nam, Is The Person I Choose As My, EEare choic PP L E P L E, oneone Phone, CityStateZip CityStateZip, Address Address Address, CiC CityStateZip, Phone, M M M M, First Choice Name, Address, and Address.

five wishes download If this person is not able or, e choices for me OROR is divorced, Second Choice Name, Third Choice Nam Third Choice Nam, Is The Person I Choose As My, EEare choic PP L E P L E, oneone Phone, CityStateZip CityStateZip, Address Address Address, CiC CityStateZip, Phone, M M M M, First Choice Name, Address, and Address fields to fill out

Inside of space p m, treatments to keep me alive, A If I Change S A S A, If I Change M If I Change My Mind, DestDest Destroy all copies of, Tell someone such as my doctor or, family that I want to cancel or, Write the word Revoked in large, whose authority I want to cancel, and M M, specify the rights and responsibilities.

p m, treatments to keep me alive, A If I Change S A S A, If I Change M If I Change My Mind, DestDest Destroy all copies of, Tell someone such as my doctor or, family that I want to cancel or, Write the word Revoked in large, whose authority I want to cancel, and M M in five wishes download

Finish by reviewing all of these areas and submitting the required data: surgery blood transfusions, M M, In Case Of An Emer In Case Of An, If you have a medical emergency, signed by a doctor This form lets, and S A.

part 5 to entering details in five wishes download

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