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Understanding how to communicate one's healthcare preferences during periods of serious illness is an overwhelming yet crucial part of personal planning. Here's where the Five Wishes document steps in—as a beacon guiding individuals in laying out their medical, personal, and emotional wishes. Designed with inputs from experts and the American Bar Association on Law and Aging, this document stands out for its simplicity and legal validity in most states once properly completed. It covers comprehensively who should make decisions when one cannot, the type of medical treatment desired or not, levels of comfort, how one wishes to be treated by others, and the essential thoughts or messages one wants to leave behind for loved ones. This compassionate approach to end-of-life planning not only clarifies one's wishes but significantly eases the decision-making burden on family members, ensuring they are not left guessing in times of crisis. Available in 27 languages and recognized in 42 states plus the District of Columbia, the Five Wishes document has touched over 19 million lives, offering a mix of legal formality with the tenderness of personal touch—making it a unique tool for articulating healthcare choices. Transitioning to Five Wishes from any previous advance directive is straightforward, ensuring that one’s current healthcare directives align with their evolving wishes and values.

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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

1HEUDVND

 

 

 

 

 

6RXWK'DNRWD

Arkansas

Kentucky

1HYDGDD

 

 

 

 

Tennessee

&DOLIRUQLD

/RXLVLDQD

1HZ-HUVH\

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vermont

 

 

&RORUDGR

Maine

1HZ0H[LFR

 

 

 

 

Virginia

 

 

&RQQHFWLFXW

Maryland

 

 

 

RUN

Washington

1HZ<

Delaware

Massachusetts

 

 

 

 

 

 

 

 

 

West Virginia

1RUWK&DUROLQD

Florida

Michigan

 

 

 

 

 

 

 

Wisconsin

1RUWK'DNRWD

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:

 

 

__

Witness Statement • (2 witnesses needed):

,WKHZLWQHVVGHFODUHWKDWWKHSHUVRQZKRVLJQHGRUDFNQRZOHGJHGWKLVIRUPKHUHDIWHU´SHUVRQµLVSHUVRQDOO\NQRZQWR PHWKDWKHVKHVLJQHGRUDFNQRZOHGJHGWKLV>+HDOWK&DUH$JHQWDQGRU/LYLQJ:LOOIRUPV@LQP\SUHVHQFHDQGWKDWKHVKH appears to be of sound mind and under no duress, fraud, or undue influence.

,DOVRGHFODUHWKDW,DPRYHU\HDUVRIDJHDQGDP127

•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.)

 

 

 

 

 

 

 

 

 

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Signature of Witness #2

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Printed Name of Witness

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Address

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

Phone

 

 

Notarization • Only required for residents of Missouri, North Carolina, South Carolina and West Virginia

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➤ PDF File

Form Specifications

Fact Name Description
Overview of Five Wishes Five Wishes is a comprehensive living will that addresses personal, emotional, spiritual needs, and medical wishes.
Legal Status Once completed and signed, it is legally valid in most states under specific statutes.
Purpose It enables individuals to outline how they wish to be treated if seriously ill, minimizing difficult decisions for family members.
Origin Inspired by Jim Towey’s experience with Mother Teresa and designed to help families plan for serious illness.
User Demographic Recommended for anyone over 18, including married, single, parents, adult children, and friends.
State Compatibility Valid in the District of Columbia and 42 states, individuals in other states may need to supplement with state-specific forms.
Transition to Five Wishes To adopt Five Wishes, individuals must revoke any prior living will or durable power of attorney for healthcare and notify relevant parties.
Choosing a Health Care Agent Details the importance of selecting a reliable health care agent who understands and respects the individual’s wishes.

5 Wishes Document: Usage Guidelines

The Five Wishes document offers a way for individuals to outline their desires regarding healthcare and personal matters in the event that they are unable to communicate their wishes themselves. This document is unique because it covers personal, emotional, and spiritual needs in addition to medical wishes. It is recognized in many states as a legal document when completed and signed appropriately. Below are step-by-step instructions for filling out the Five Wishes Document to ensure your preferences are known and respected.

  1. Wish 1: Choosing Your Health Care Agent
    1. Begin by considering who you trust to make healthcare decisions on your behalf if you're unable to do so. This person will be your Health Care Agent.
    2. In the designated sections, write the name, address, and phone number of your first choice for Health Care Agent.
    3. Identify and document second and third choices for your Health Care Agent, including their contact information, to act in the role should your first choice be unable to fulfill their duties.
  2. Guidelines for Your Health Care Agent
    • Think about the decisions your agent may have to make. These could range from medical treatment options to end-of-life care.
    • Document any specific wishes you have about your medical care, including treatments you do or do not want.
    • Discuss your wishes with the person you've chosen to ensure they are willing and understand your preferences.
  3. Powers of Your Health Care Agent
    • Carefully review the list of actions your Health Care Agent can take on your behalf. Cross out any powers you do not wish to grant them.
    • If there are specific limitations or additional instructions you want to include regarding the powers of your Health Care Agent, write these down in the provided spaces.
  4. Communicating Your Wishes
    • Have detailed conversations with your chosen agent(s) about your healthcare preferences, ensuring they understand the responsibility and your expectations.
    • Inform family members, close friends, and your healthcare providers about your Five Wishes document and who you have chosen as your Health Care Agent.
  5. Finalizing the Document
    • Once completed, your Five Wishes document needs to be signed as required by your state's laws to be legally valid. This may include signing in the presence of witnesses or a notary, depending on local regulations.
    • Distribute copies of the signed document to your Health Care Agent, alternative agents, family members, and healthcare providers to ensure your wishes are known.
  6. Review and Update as Necessary
    • Periodically review your Five Wishes document to make sure it still reflects your desires, especially after major life changes such as marriage, divorce, the birth of a child, or a significant change in health.
    • If you decide to change your Health Care Agent or any of your wishes, update your Five Wishes document, destroy all copies of the old version, and notify everyone who had a copy of the changes.

By carefully completing the Five Wishes document, you take a significant step toward ensuring your healthcare preferences are honored. Remember, open and honest communication with your chosen Health Care Agent and loved ones about your wishes is key to this process.

Your Questions, Answered

What is the Five Wishes Document?

The Five Wishes Document is an innovative tool that addresses not only medical wishes but also personal, emotional, and spiritual desires in the event of a serious illness. It's considered the first living will of its kind, designed to guide family, friends, and healthcare providers about how one wishes to be treated if they are unable to communicate their wishes themselves. It allows an individual to appoint a Health Care Agent to make decisions on their behalf, specify types of medical treatment desired, detail comfort measures, identify how they wish to be treated by others, and express any final messages to loved ones.

Who should use Five Wishes?

Any person over the age of 18 can benefit from completing a Five Wishes document. This includes individuals who are married, single, parents, adult children, or friends. It has gained widespread acceptance, with over 19 million people having used it. Its versatility makes it a helpful resource for attorneys, medical professionals, hospitals, hospices, faith groups, employers, and retirement organizations to distribute and discuss within their communities.

Is the Five Wishes Document legally valid in all states?

Five Wishes meets the legal requirements for an advance directive in the District of Columbia and 42 states. In these locations, filling out and signing the document provides a legally binding expression of one’s desires regarding medical treatment and end-of-life care. However, if you live outside these states, while your medical wishes might not meet the technical statutes of your state, Five Wishes can still serve as a powerful guide for your loved ones and healthcare providers. It's always recommended to check with your state's requirements or a legal professional for guidance.

How can Five Wishes help families?

Five Wishes facilitates open and meaningful conversations among family members about preferences in medical treatment, comfort, and personal sentiments at the end of life. It provides clarity and reassurance to both the individual and their loved ones, significantly reducing the stress of making tough decisions during emotional times. The document ensures that family members are aware of their loved one's wishes, eliminating the need for guesswork and potentially conflicted decisions among relatives and healthcare providers.

How do I change to Five Wishes from another advance directive?

If you already have an existing living will or durable power of attorney for healthcare but wish to switch to the Five Wishes document, you simply need to complete a new Five Wishes form and sign it as directed. Upon doing this, it's important to nullify any previous advance directives by either destroying them or writing "revoked" across the documents. Inform your health care agent, family members, and doctor of this change to ensure that everyone involved in your care is up to date with your current wishes.

How do I choose the right person to be my Health Care Agent?

Choosing your Health Care Agent is one of the most critical decisions in the Five Wishes process. Select someone you trust deeply, knows you well, and understands your values and wishes. This person should also be capable of making difficult healthcare decisions under stress. While family members are common choices, it's essential to consider their emotional capacity to make such decisions. Discuss your wishes with the chosen individual to ensure they are willing and able to act on your behalf when required.

Common mistakes

Filling out the 5 Wishes Document is a critical step in planning for your future medical care. However, mistakes can often be made during this process. Being aware of common errors can help ensure your wishes are clearly expressed and followed. Here are five common mistakes to avoid:

  1. Not Choosing the Right Health Care Agent: It’s crucial to designate a Health Care Agent who truly knows you and can reliably act on your behalf. This individual should not only be trustworthy but also possess the emotional strength to make difficult decisions under pressure.

  2. Being Vague About Medical Treatment Wishes: Failing to specify your desires regarding medical treatment, including life-sustaining measures, can lead to actions that may or may not align with what you would have wanted. Clear and detailed instructions ensure your healthcare team knows your exact preferences.

  3. Overlooking Comfort and Care Preferences: Comfort and care preferences extend beyond medical treatments to include personal dignity and emotional well-being. Neglecting to detail how you wish to be made comfortable, and how you wish people to treat you, can result in care that does not meet your personal standards or desires.

  4. Not Communicating Wishes to Your Loved Ones: Failing to discuss your wishes with family and your designated Health Care Agent can lead to uncertainty and stress during difficult times. Open conversations can reassure your loved ones that they are honoring your preferences.

  5. Improper Signing or Not Meeting State Requirements: Each state has its own legal requirements for making the 5 Wishes Document valid. Not thoroughly completing, signing, or following your state’s specific processes can render the document ineffective. This highlights the importance of understanding and adhering to your local laws.

Avoiding these mistakes requires thoughtful consideration, clear communication, and occasionally, guidance from professionals knowledgeable about your state's laws. Taking these steps ensures that your healthcare wishes are respected and followed, providing peace of mind for both you and your loved ones.

Documents used along the form

When preparing for the future, especially regarding healthcare decisions, the Five Wishes Document is a valuable tool that allows individuals to outline their preferences clearly. Along with the Five Wishes Document, there are several other forms that can play a pivotal role in ensuring one's wishes are respected and followed. These documents complement the Five Wishes by covering additional aspects of advance planning.

  • Durable Power of Attorney for Health Care: This document allows you to appoint someone to make healthcare decisions on your behalf if you become unable to do so. Unlike the Five Wishes, which covers personal, emotional, and spiritual needs along with medical wishes, a Durable Power of Attorney for Health Care strictly designates a decision-maker.
  • Living Will: A living will is a written document that specifies the types of medical treatments and life-sustaining measures you want or don't want if you're unable to communicate your decisions. It focuses on end-of-life care, such as the use of ventilators and feeding tubes.
  • Last Will and Testament: Though not directly related to healthcare decisions, a Last Will and Testament is crucial for outlining how you want your assets distributed after your death. It also allows you to appoint a guardian for minor children.
  • Do Not Resuscitate (DNR) Order: A DNR order is a medical order that tells healthcare professionals not to perform CPR if your breathing stops or if your heart stops beating. It's different from the above documents because it's used in emergency medical situations and goes into effect immediately upon your incapacity.

These documents, used together, can provide a comprehensive plan for your healthcare and personal wishes, offering peace of mind for both you and your family. Each serves a unique purpose, addressing different aspects of your care and ensuring that your values and preferences are honored. Preparing these forms in advance is a profound act of care for yourself and your loved ones.

Similar forms

  • Living Will: Similar to the Five Wishes document, a living will enables individuals to outline their preferences regarding the medical treatments they want to receive or refuse, particularly life-sustaining measures, when they're unable to communicate these decisions themselves. Both documents are aimed at guiding healthcare providers and loved ones in making care decisions that align with the individual's wishes.

  • Durable Power of Attorney for Healthcare: This legal document allows a person to appoint another individual to make healthcare decisions on their behalf if they become unable to do so. It is similar to the first wish in the Five Wishes document, where one nominates a health care agent, but it typically focuses more on the delegation of decision-making authority rather than on specific care preferences.

  • Do Not Resuscitate (DNR) Order: A DNR is a medical order that tells healthcare providers not to perform CPR if a patient's breathing stops or if the heart stops beating. The Five Wishes document covers a broader range of treatments and care preferences, but similar to a DNR, it may include wishes about not wanting certain life-sustaining treatments.

  • Medical Orders for Life-Sustaining Treatment (MOLST) or Physician Orders for Life-Sustaining Treatment (POLST): These medical orders translate a patient’s wishes into actionable medical orders, applicable across a variety of healthcare settings. Similar to Five Wishes, these documents address critical decisions like the use of ventilators, feeding tubes, and other life-sustaining treatments based on the patient’s values and goals for care.

  • Hospice Care Instructions: These instructions outline a patient’s wishes regarding end-of-life care, focusing on comfort and quality of life rather than curative treatments. The Five Wishes document also addresses how comfortable a person wants to be (Wish 3), including pain management and palliative care preferences, aligning closely with the principles of hospice care.

  • Organ and Tissue Donation Registration: This expresses an individual's decision regarding the donation of organs and tissues after death. While primarily a registration rather than a comprehensive document, it can relate to the medical care decisions outlined in the Five Wishes, specifically if an individual includes wishes about organ donation as part of their end-of-life care preferences (within Wish 5).

Dos and Don'ts

When completing the Five Wishes Document form, making thoughtful decisions can help ensure your health care preferences are respected. Here are some essential dos and don'ts to consider:

  • Do take your time to thoroughly read and consider each section before you make any decisions.
  • Do discuss your wishes with the person you intend to appoint as your Health Care Agent to make sure they understand and are willing to respect your choices.
  • Do provide clear, specific instructions about your medical treatment preferences to avoid any confusion later on.
  • Do use the space provided for additional instructions to detail any beliefs, values, or preferences that you want your Health Care Agent and caregivers to consider.
  • Do sign and date the document in the presence of the required witnesses or a notary, depending on your state’s laws, to ensure it's legally valid.
  • Don't choose a Health Care Agent without considering their ability to act on your behalf under stressful circumstances.
  • Don't leave any sections blank; if certain wishes don't apply or you prefer not to choose, indicate this clearly to avoid any potential oversights.
  • Don't forget to inform family members, close friends, and your primary physician where your completed Five Wishes Document is stored.
  • Don't hesitate to update your document if your wishes change. Ensure you destroy all copies of the old document and communicate the changes to everyone involved.

Completing the Five Wishes Document is a proactive step in planning for your future health care. It helps alleviate the burden on loved ones during challenging times by clearly outlining your health care preferences. Ensuring all steps are followed correctly and your document is kept up to date will support the execution of your wishes as intended.

Misconceptions

Many misconceptions surround the Five Wishes Document, a critical form for expressing healthcare preferences. Understanding these can ensure wishes are honored accurately.

  • Misconception 1: The Five Wishes Form is legally valid in all 50 states.

    While the Five Wishes document is designed to meet the legal requirements in 42 states and the District of Columbia, not all states automatically recognize it as a legal document without accompanying state-specific forms.

  • Misconception 2: The document is challenging to fill out.

    Contrary to some beliefs, the Five Wishes document is user-friendly, written in simple language designed to be easy for anyone to complete without legal assistance.

  • Misconception 3: It's only for the elderly or those with terminal conditions.

    The document is recommended for anyone over the age of 18, regardless of health status, to ensure their healthcare preferences are known and respected.

  • Misconception 4: It can only be executed by legal professionals.

    Actually, individuals can complete and sign the form themselves, as long as it's witnessed correctly according to the laws of their state.

  • Misconception 5: It replaces the need for a Durable Power of Attorney for Healthcare (DPOA).

    While the Five Wishes document includes naming a healthcare proxy, it serves broader purposes than a DPOA, covering personal, emotional, and spiritual needs in addition to medical wishes.

  • Misconception 6: Once signed, it cannot be changed.

    Individuals can update their Five Wishes document any time as their circumstances or preferences change, but must ensure it is re-signed, witnessed, and others are informed about the update.

  • Misconception 7: Doctors can ignore the document if it conflicts with their medical advice.

    Healthcare providers are generally required to follow the wishes as expressed in the document, unless doing so would violate their professional responsibilities or the law.

  • Misconception 8: It covers financial decisions as well as healthcare.

    The Five Wishes document strictly pertains to healthcare decisions and does not encompass financial powers or responsibilities.

  • Misconception 9: It is only effective in a hospital setting.

    The document guides healthcare decisions in any setting, including at home, in hospice care, or in residential care facilities.

  • Misconception 10: Filling out the form means giving up control of healthcare decisions immediately.

    The directive only takes effect under specific conditions, such as if the individual becomes unable to make decisions on their own behalf.

Dispelling these misconceptions is crucial in empowering individuals to take proactive steps toward ensuring their healthcare wishes are understood and respected.

Key takeaways

The Five Wishes document is a comprehensive way to communicate your preferences concerning medical treatment, comfort, and how you want to be treated in case you become seriously ill. Here are key takeaways for completing and using this document:

  • Universal Application: Five Wishes is designed to meet the legal requirements in 42 states plus the District of Columbia, making it broadly applicable for most individuals in the United States.
  • Comprehensive Coverage: Unlike a standard living will, Five Wishes covers personal, emotional, and spiritual needs alongside medical choices, providing a holistic approach to end-of-life planning.
  • Clear Communication: By setting out your wishes in advance, the document helps families avoid difficult decisions and disagreements during stressful times, ensuring your wishes are respected.
  • Designating a Health Care Agent: Five Wishes allows you to nominate a trusted person to make health care decisions on your behalf if you become unable to do so, ensuring decisions are made by someone who understands your desires.
  • Detailed Preferences: You can specify the type of medical treatment you want or don't want, how you wish to be made comfortable, how you expect to be treated, and what you want your loved ones to know.
  • Changing Your Mind: The document is flexible; you can revoke or amend it if your circumstances or wishes change, offering peace of mind that your directive remains up-to-date.
  • Legal Validation: Once completed and properly signed, Five Wishes becomes a valid legal document in the states where it is recognized, making it an essential part of estate and healthcare planning.
  • Accessibility: The document is available in 27 languages, making it accessible to a wide audience, and it is designed for anyone 18 years or older, ensuring that adults at any stage of life can utilize it.

In conclusion, the Five Wishes document is a powerful tool for communicating your healthcare and personal wishes. Its ease of use, combined with its comprehensive approach, makes it a valuable resource for ensuring your desires are known and respected.

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