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
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
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How Five Wishes Can Help You And Your Family
•It lets you talk with your family, friends and doctor about how you wantt to be treated if you become seriously ill.
•Your family members will not have to guess what you want. It protects them if you become seriously ill, because
How Five Wishes Began
For 12 years, Jim Towey worked closely with
Mother Teresa, and, for one year, he lived in a
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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
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•You can know what your mom, dad, spouse, or friend wants. You can be there for them when they need you most. You will understand what they really want.
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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
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requirements under the law:
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If your state is not one of the 42 states listed here, Five Wishes does not meet the technical
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to honor Five Wishes. However, many people from states not on this list do complete Five
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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:
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estroy all copies of your old living will |
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or durable power of attorney for health |
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members, and doctor that you have |
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care. Or you can write “revoked” in large |
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filled out a new Five Wishes. |
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letters across the copy you have. Tell |
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your lawyer if he or she helped prepare |
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new wishes. |
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those old forms for you. AND |
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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 |
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• My attending or treating doctor finds I am no |
I decisions, this form names the person I choose to |
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longer able to make health ca |
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re choic |
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make these choices for me. This person will be my |
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• Another health care profe |
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Health Care Agent (or other term that may be used in |
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this is true. |
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my state, such as proxy, representative, or surrogate). |
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If my state has a different |
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ay of finding that I am not |
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This person will make my health care choices if both |
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able to make health c |
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are choices, then my state’s way |
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of these things happen: |
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should be followe |
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The Person I Choose As My Health Care Agent Is: |
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First Choice Name |
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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:
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Picking The R |
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Your Health Care Agent |
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ight Person To Be |
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can make difficult |
Agent should be at least 18 years or older (in |
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cares about you, and who |
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ily member may |
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decisions. A spouse or fam |
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not be the best choice because they are too |
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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. |
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ho is able to stand up for you so that your |
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wishes are followed. Also, choose someone who |
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An employee or spouse of an employee of |
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is likely to be nearby so that they can help when |
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your health care provider. |
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you need them. Whether you choose a spouse, |
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Agent, make sure you talk about these wishes |
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more people unless he or she is your |
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and be sure that this person agrees to respect |
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spouse or close relative. |
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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 or services, like tests, medicine, or surgery. This care or service could be to find out what my health problem is, or how to treat it. It can also include care to keep me alive. If the treatment or
FDUHKDVDOUHDG\VWDUWHGP\+HDOWK&DUHAgent can keep it going or have it stopped.
•Interpret any instructions I have given in
this form or given in other discussions, according
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hospital, hospice, or nursing home for me. My
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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.
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and personal files. If I need to sign my name to
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sign it for me.
•Move me to another state to get the care I need or to carry out my wishes.
•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
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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
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Destroy all copies of this part of the |
• Write the word “Revoked” in large |
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Five Wishes form. OR |
letters across the name of each agent |
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• Tell someone, such as my doctor or |
whose authority I want to cancel. |
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family, that I want to cancel or change |
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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
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dure, device or medication to keep me alive.
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devices put in me to help me breathe; food and
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surgery; blood transfusions; dialysis; antibiotics;
and anything else meant to keep me alive.
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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.
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In Case Of An Emergency
Iff |
you have a medical emergency and |
signed by a doctor. This form lets ambulance |
ambulance personnel arrive, they may look |
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to see if you have a Do Not Resuscitate form |
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or bracelet. Many states require a person to |
check with your doctor to see if you need to have |
have a Do Not Resuscitate form filled out and |
a Do Not Resuscitate form filled out. |
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
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been started, I want it stopped.
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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
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support treatment would only delay the moment of my
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been started, I want it stopped.
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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
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been started, I want it stopped.
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In Another Condition Under Which I Do Not Wish To Be Kept Alive:
If there is another condition under which I do not wish
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this condition, I believe that the costs and burdens of
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benefits to me. Therefore, in this condition, I do not want
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gotten worse. You are not able to take care of yourself in
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will not help you recover. Please leave the space blank if
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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.
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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.
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
•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
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______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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$JHQWLI,KDYHRQHDQGKH RUVKHLVDYDLODEOHRUDVRWKHUZLVHH[SUHVVHGLQWKLVIRUP7KLVIRUPEHFRPHVYDOLGZKHQ,DPXQDEOHWRPDNH decisions or speak for myself. If any part of this form cannot be legally followed, I ask that all other parts of this form be followed. I also revoke any health care advance directives I have made before.
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Address: |
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Witness Statement • (2 witnesses needed):
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appears to be of sound mind and under no duress, fraud, or undue influence.
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•The individual appointed as (agent/proxy/
VXUURJDWHSDWLHQWDGYRFDWHUHSUHVHQWDWLYHE\ this document or his/her successor,
•7KHSHUVRQ·VKHDOWKFDUHSURYLGHULQFOXGLQJ RZQHURURSHUDWRURIDKHDOWKORQJWHUPFDUH or other residential or community care facility serving the person,
•$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 #1
Printed Name of Witness
Address
Phone
Signature of Witness #2
Printed Name of Witness
Address
Phone
Notarization • Only required for residents of Missouri, North Carolina, South Carolina and West Virginia
•If you live in Missouri, only your signature should be notarized.
•,I\RXOLYHLQ1RUWK&DUROLQD6RXWK&DUROLQDRU:HVW9LUJLQLD you should have your signature, and the signatures of your witnesses, notarized.
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acknowledged that they freely and voluntarily executed the same for the purposes stated therein.
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What To Do After You Complete Five Wishes
•0DNHVXUH\RXVLJQDQGZLWQHVVWKHIRUPMXVW the way it says in the directions. Then your Five Wishes will be legal and valid.
•Talk about your wishes with your health care agent, family members and others who care about you. Give them copies of your completed Five Wishes.
•Keep the original copy you signed in a
VSHFLDOSODFHLQ\RXUKRPH'R127SXW it in a safe deposit box. Keep it nearby so that someone can find it when you need it.
•)LOORXWWKHZDOOHWFDUGEHORZ&DUU\LWZLWK you. That way people will know where you keep your Five Wishes.
•Talk to your doctor during your next office visit. Give your doctor a copy of your Five Wishes. Make sure it is put in your medical record. Be sure your doctor understands your wishes and is willing to follow them. Ask himm or her to tell other doctors who treat you too honor them.
•If you are admitted to a hospital or nursing home, take a copy of your Five Wishess with you. Ask that it be put in your medical record.
•I have given the following people copies of my completed Five Wishes:
________________________________________
_______________
__________________
Residents of WISCONSIN must attach the WISCONSIN notice statement to Five Wishes.
More information and the notice statementt are available at www.agingwithdignity.orgRU
Residents of Institutions In CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, NEW YORK,
NORTH DAKOTA, SOUTH CAROLINA, and VERMONT Must Follow Special Witnessing Rules.
If you live in certain institutions (a nursing home, other licensed long term care facility, a home for the mentally
UHWDUGHGRUGHYHORSPHQWDOO\GLVDEOHGRUDPHQWDOKHDOWKLQVWLWXWLRQLQRQHRIWKHVWDWHVOLVWHGDERYH\RXPD\ have to follow special “witnessingg requirements” for your Five Wishes to be valid. For further information, please contact a social worker or patient advocate at your institution.
Five Wishes is meant to help you plan for the future. It is not meant to give you legal advice. It does not try to answer all questions about anything that could come up. Every person is different, and every situation is different. Laws change from time to time. If you have a specific question or problem, talk to a medical or legal professional for advice.
✁)LYH:LVKHV:DOOHW&DUG
,PSRUWDQW1RWLFHWR0HGLFDO3HUVRQQHO I have a Five Wishes Advance Directive.
__________________________
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3OHDVHFRQVXOWWKLVGRFXPHQWDQGRUP\+HDOWK&DUH Agent in an emergency. My Agent is:
___________________________________
1DPH
_________________________________________
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_________________________________________
Phone
My primary care physician is:
________________________________________
1DPH
________________________________________
$GGUHVV &LW\6WDWH=LS
________________________________________
Phone
My document is located at:
________________________________________
________________________________________
________________________________________
________________________________________
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Here’s What People Are Saying About Five Wishes:
“It will be a year since my mother passed on. We knew what she wanted because she had the Five Wishes living will. When it came down to the end, my brother and I had no questions on what we needed to do. We had peace of mind.”
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issues of medical care, but on the issues of real importance—human care. I used
it for myself and my husband.”
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I never knew that there were so many medical options to be considered. Thank you for such a sensitive and caring form. I can simply fill it out and have it on file for my children.”
Diana W.
Hanover, Illinois
To Order:
&DOO:,6+(6 to purchase more copies of Five Wishes,
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(888)5-WISHESRU
www.agingwithdignity.org
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