The Five Wishes document is a legal form that allows individuals to express their personal, emotional, and spiritual needs in addition to their medical wishes. It empowers users to designate a trusted person to make healthcare decisions on their behalf when they are unable to do so. This user-friendly form ensures that personal preferences regarding medical treatment and care are honored, providing peace of mind for both the individual and their loved ones.
To take control of your healthcare decisions, consider filling out the Five Wishes document by clicking the button below.
The Five Wishes document serves as a vital tool for individuals seeking to articulate their healthcare preferences in the event of a serious illness. This form allows individuals to designate a trusted person to make medical decisions on their behalf when they are unable to do so. It encompasses not only medical treatment preferences but also addresses personal comfort, emotional support, and the way individuals wish to be treated by caregivers and loved ones. The document encourages open communication among family members, alleviating the burden of making difficult decisions during challenging times. Developed with insights from legal experts and healthcare professionals, Five Wishes is designed to be user-friendly, requiring only simple checkboxes, circles, or brief written responses to convey one’s wishes. Valid in many states, it empowers individuals to take control of their healthcare journey, ensuring that their values and desires are honored even when they cannot voice them themselves. This comprehensive approach to advance care planning makes Five Wishes accessible to a wide audience, including anyone aged 18 and older, and has garnered attention and endorsement from various organizations across the country.
M Y W I S H F O R :
The Person I Want to Make Care1Decisions for Me When I Can’t
The Kind of Medical Treatment2 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
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T here are many things in life that are out of our hands. This Five Wishes document gives you a way to control something very important — how
you are treated if you get seriously ill. It is an 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 of most states.
What Is Five Wishes?
Five Wishes is the first living will (also called an advance directive) 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 yourself. 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 nation’s leading experts in end-of-life care. It’s also easy to use. All you have to do is 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, friends and
they won’t have to make hard choices
doctor about how you want to be treated if
without knowing your wishes.
you become seriously ill.
• You can know what your mom, dad,
• Your family members will not have to guess
spouse, or friend wants. You can be there
what you want. It protects them
for them when they need you most. You will
if you become seriously ill, because
understand what they really want.
How Five Wishes Began
For 12 years, Jim Towey worked closely with Mother Teresa, and, for one year, he lived in a hospice she ran in Washington, DC. Inspired by this first-hand experience, Mr. Towey sought a way for patients and their families to plan ahead and to cope with serious illness. The result is Five Wishes and the response to it has been overwhelming. It has been featured on CNN and NBC’s Today Show and in the pages of Time and Money magazines. Newspapers have called Five Wishes the first “living will with a heart and soul.” Today, Five Wishes is available in 30 languages.
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Who Should Use Five Wishes
Five Wishes is for anyone 18 or older — married, single, parents, adult children, and friends. More than 40 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 out this document.
People who use Five Wishes find that it helps them express 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.
Five Wishes In My State
Five Wishes was created with help from the American Bar Association’s Commission on Law and Aging. If you live in the District of Columbia or most states you can use Five Wishes and have the peace of mind to know that it substantially meets your state’s requirements under the law. If you live in one of four states (Kansas, New Hampshire, Ohio, or Texas) you can still use Five Wishes but may need to take an extra step. Find out more at FiveWishes.org/states.
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:
• Destroy all copies of your old living will or
• Tell your Health Care Agent, family
durable power of attorney for healthcare.
members, and doctor that you have filled out
Or you can write “revoked” in large letters
a new Five Wishes. Make sure they know
across the copy you have. Tell your lawyer
about your new wishes.
if he or she helped prepare those old forms
for you.
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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.
I f I am no longer able to make my own health care decisions, this form names the person I choose to
make these choices for me. This person will be my Health Care Agent (or other term that may be used in my state, such as proxy, representative, or surrogate). This person will make my health care choices if both of these things happen:
•My attending or treating doctor finds I am no longer able to make health care choices, AND
•Another health care professional agrees that this is true.
If my state has a different way of finding that I am not able to make health care choices, then my state’s way should be followed.
The Person I Choose As My Health Care Agent Is:
First Choice Name
Phone
Address
City/State/Zip
If this person is not able or willing to make these choices for me, OR is divorced or legally separated from me, OR this person has died, then these people are my next choices:
Second Choice Name
Third Choice Name
Picking The Right Person To Be Your Health Care Agent
Choose someone who knows you very well, cares about you, and who can make difficult decisions. A spouse or family member may not be the best choice because they are too emotionally involved. Sometimes they are the best choice. You know best. Choose someone who is able to stand up for you so that your wishes are followed. Also, choose someone who is likely to be nearby so they can help when you need them. Whether you choose a spouse, family member, or friend as your Health Care Agent, make sure you talk about these wishes and be sure that this person agrees to respect and
follow your wishes. Your Health Care Agent should be at least 18 years or older (in Colorado,
21 years or older) and should not be:
• Your health care provider, including the owner or operator of a health or residential or community care facility serving you.
• An employee or spouse of an employee of your health care provider.
• Serving as an agent or proxy for 10 or more people unless he or she is your 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 care has already started, my Health Care Agent can keep it going or have it stopped.
• Interpret any instructions I have given in this form or given in other discussions, according to my Health Care Agent’s understanding of my wishes and values.
• Consent to admission to an assisted living facility, hospital, hospice, or nursing home for me. My Health Care Agent can hire any kind of health 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 give medical treatments, including artificially- provided food and water, and any other treatments to keep me alive.
• See and approve release of my medical records and personal files. If I need to sign my name to get any of these files, my Health Care Agent can 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 or insurance benefits for me. My Health Care
Agent can see my personal files, like bank records, to find out what is needed to fill out these forms.
• Listed below are any changes, additions, or limitations on my Health Care Agent’s powers.
If I Change My Mind About Having A Health Care Agent, I Will
• Destroy all copies of this part of the Five Wishes
• Write the word “Revoked” in large letters across
form. OR
the name of each agent whose authority I want to
• Tell someone, such as my doctor or family, that I
cancel. Sign my name on that page.
want to cancel or change my Health Care Agent.
OR
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WISH 2
My Wish For The Kind Of Medical Treatment
I Want Or Don’t Want.
I believe that my life is precious and I deserve to be treated with dignity. When the time 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 to be
• I do not want anything done or omitted by my
comfortable. Wish 3 says what can be done to
doctors or nurses with the intention of taking
make me comfortable.
my life.
• I want to be offered food and fluids by mouth if it is safe for me to eat and drink. I want to be kept clean and warm.
What “Life-Support Treatment” Means To Me
Life-support treatment means any medical procedure, device, or medication to keep me alive. Life-support treatment includes: medical devices put in me to help me breathe; food and water supplied by medical device (tube feeding); cardiopulmonary resuscitation (CPR); major surgery; blood transfusions; dialysis; antibiotics; and anything else meant to keep me alive. If I wish to limit the meaning of life-support 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
If 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 if you choose not to be
resuscitated. This form lets ambulance personnel know that you don’t want them to use life-support treatment when you are dying. Please check with your doctor to see if you need to have a Do Not Resuscitate form filled out.
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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 time, and life-support treatment would only delay the moment of my death (choose one of the following):
oI want to have life-support treatment.
oI do not want life-support treatment. If it has been started, I want it stopped.
oI want to have life-support treatment if my doctor believes it could help. But I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.
In A Coma And Not Expected To 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 to wake up or recover, and I have brain damage, and life-support treatment would only delay the moment of my death (choose one of the following):
Permanent And Severe Brain Damage And Not Expected To Recover:
If my doctor and another health care professional both decide that I have permanent and severe brain damage, (for example, I can open my eyes, but I can not speak or understand) and I am not expected to get better, and life‑support treatment would only delay the moment of my death (choose one of the following):
In Another Condition Under Which I Do Not Wish To Be Kept Alive:
If there is another condition under which I do not wish to have life-support treatment, I describe it below. In this condition, I believe that the costs and burdens of life-support treatment are too much and not worth the benefits to me. Therefore, in this condition, I do not want life-support treatment. (For example, you may write “end-stage condition.” That means that your health has gotten worse. You are not able to take care of yourself in any way, mentally or physically. Life- support treatment will not help you recover. Please leave the space blank if you have no other condition to describe.)
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T he 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 me the proper care asked for by law.
WISH 3
My Wish For How Comfortable I Want To Be.
(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 on 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 wish to be massaged with warm oils as often as I can be.
• 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 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.
• I wish to have religious or spiritual readings and well-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.
• 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 be visited by a chaplain or clergy.
• I wish to be cared for with kindness and cheerfulness, and not sadness.
• I wish to have my hand held and to be talked to when possible, even if I don’t seem to 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 have pictures of my loved ones in my room, near my bed.
• I wish to have my favorite music played when possible until my time of death.
• I want to die in my home, if that can be done.
• I wish to be called by my name. Please call me:
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WISH 5
My Wish For What I Want My Loved Ones To Know.
• 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 and caregivers to respect my wishes even if they don’t agree with them.
• 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 live a meaningful life in my final days.
• I wish for my family and friends to know that I do not fear death. 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 to remember me in this way after my death.
• 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 them joy and not sorrow.
• After my death, I would like my body to be
(circle one): buried OR cremated.
• 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 be a memorial service for me, I wish for this service to include the following (list music, songs, readings, or other specific requests that you have):
It is important for my health care providers to know what matters most to me. I wish for them to know the following:
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. Or you may want to give instructions on what should be done with your social media or other electronic records. Please attach a separate sheet of paper if you need more space.
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Signing My Five Wishes
Please make sure you sign your Five Wishes in the presence of two witnesses.
I,
, ask that my family, my doctors, and other health care providers, my
friends, and all others, follow my wishes as communicated by my Health Care Agent (if I have one and he or
she is available), or as otherwise expressed in this form. This form becomes valid when I am unable to make 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
Date
Address (cont.)
Witness Statement • (2 witnesses needed):
I, the witness, declare that the person who signed or acknowledged this form (hereafter “person”) is personally known to me, that he/she signed or acknowledged this [Health Care Agent and/or Living Will form(s)] in my presence, and that he/she appears to be of sound mind and under no duress, fraud, or undue influence.
I also declare that I am over 18 years of age (19 in Alabama) and am NOT:
• The individual appointed as (agent/proxy/ surrogate/patient advocate/representative) by this document or his/her successor,
• The person’s health care provider, including owner or operator of a health, long-term care, or other residential or community care facility serving the person,
• An employee of the person’s health care provider,
• Financially responsible for the person’s health care,
• An employee of a life or health insurance provider for the person,
• Related to the person by blood, marriage, or adoption,
• A beneficiary of any legal instrument, account, or benefit plan of the person, 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
Signature of Witness #2
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. If you live in North Carolina, South Carolina or West Virginia, you should have your signature, and the signatures of your witnesses, notarized.
STATE OF___________________________________COUNTY OF________________________________
On this _____ day of __________________, 20_____, the said ________________________________________________________,
_______________________________, and ______________________________, known to me (or satisfactorily proven) to be the person named in
the foregoing instrument and witnesses, respectively, personally appeared before me, a Notary Public, within and for the State and County aforesaid, and acknowledged that they freely and voluntarily executed the same for the purposes stated therein.
My Commission Expires:
Notary Public
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Filling out the Five Wishes document is an important step in ensuring your healthcare preferences are known and respected. This form allows you to express your wishes clearly and designate someone to make healthcare decisions on your behalf if you are unable to do so. After completing the form, it is essential to sign it properly to ensure it is valid according to your state's laws.
What is the Five Wishes document?
The Five Wishes document is a unique living will that addresses not only medical preferences but also personal, emotional, and spiritual needs. It allows individuals to specify how they want to be treated in the event of a serious illness, including designating a person to make healthcare decisions on their behalf if they are unable to do so.
Who should use the Five Wishes document?
Anyone aged 18 or older can benefit from the Five Wishes document. This includes married individuals, singles, parents, adult children, and friends. Over 19 million people have utilized this document, which is also distributed by healthcare professionals, hospitals, and community organizations.
How does Five Wishes help families?
Five Wishes facilitates important conversations among family members regarding healthcare preferences. By clearly outlining wishes, it alleviates the burden on loved ones who might otherwise have to make difficult decisions without knowing what the individual truly desires. This document fosters understanding and support during challenging times.
Is Five Wishes legally valid?
Yes, Five Wishes is legally recognized in the District of Columbia and in 42 states across the U.S. It meets the legal requirements for advance directives in these jurisdictions. However, it is essential to check your state’s specific laws to ensure compliance.
How do I change my existing living will to Five Wishes?
To switch to Five Wishes, simply fill out and sign the new document. This action revokes any prior living wills or durable powers of attorney for healthcare. It is crucial to destroy old copies and inform your healthcare agent and family about the change to ensure everyone is aware of your current wishes.
What choices can I make in the Five Wishes document?
In the Five Wishes document, you can specify your healthcare agent, outline your medical treatment preferences, express how comfortable you want to be, and describe how you wish to be treated by others. You can also communicate any messages you want your loved ones to know, ensuring that your values and desires are honored.
Can I use Five Wishes if I live in a state not listed?
If your state is not among the 42 where Five Wishes is legally recognized, you can still complete the document. Many individuals in these states find that it helps them articulate their wishes, which healthcare providers are generally encouraged to respect, regardless of the document's legal standing.
How can I ensure my healthcare agent understands my wishes?
It is vital to have open discussions with your chosen healthcare agent about your preferences and values. Make sure they are comfortable with their role and willing to advocate for your wishes. Regular conversations can help reinforce their understanding and commitment to honoring your choices.
What should I do if I change my mind about my healthcare agent?
If you decide to change your healthcare agent, you must destroy all copies of that section of the Five Wishes document or write “Revoked” across their name. Inform your healthcare agent and family members about this change to ensure clarity and avoid any confusion in the future.
When filling out the Five Wishes document, people often make several common mistakes that can lead to confusion or invalidation of their wishes. One frequent error is not selecting a clear health care agent. This document allows you to name a person to make decisions on your behalf, but if you fail to provide a specific name or leave it blank, your wishes may not be honored. It's essential to choose someone who understands your values and is willing to advocate for you.
Another mistake is failing to communicate your wishes to the chosen health care agent. Even if you select the right person, they may not know your preferences unless you discuss them. It's crucial to have open conversations about your desires regarding medical treatment and end-of-life care. Without this dialogue, your agent may struggle to make decisions that align with your values.
People also often overlook the importance of updating the document. Life changes, such as moving to a new state, getting married, or experiencing a change in relationships, can affect your choices. If your circumstances change, revisit the Five Wishes document to ensure it reflects your current desires. Failure to do so may lead to outdated or irrelevant decisions being made on your behalf.
Additionally, individuals sometimes neglect to sign and date the document properly. A signature is vital for the document to be considered valid. Without it, health care providers may disregard your wishes. Always ensure that you follow the instructions for signing, and consider having witnesses or a notary if required by your state.
Another common oversight is not reviewing the legal requirements specific to your state. While Five Wishes is valid in many states, some have particular stipulations that must be met. Familiarize yourself with your state's laws to ensure that your document complies. Ignoring these details could result in your wishes not being honored.
Lastly, many people fail to distribute copies of the completed document to relevant parties. After filling out the Five Wishes document, share it with your health care agent, family members, and medical providers. This ensures that everyone involved is aware of your preferences and can act accordingly when the time comes. Without proper distribution, your wishes might remain unknown when they matter most.
When considering end-of-life planning, the Five Wishes document is a vital tool. However, it is often used alongside other important forms and documents that help clarify your wishes and ensure they are honored. Below is a list of related documents that can complement the Five Wishes form.
These documents work together to create a comprehensive plan for your health care and end-of-life wishes. It is important to discuss these forms with your loved ones and ensure that they are easily accessible when needed. By preparing these documents, you can provide clarity and peace of mind for both yourself and your family.
The Five Wishes Document is a valuable tool for individuals looking to express their healthcare preferences. It shares similarities with several other important documents related to healthcare decisions and end-of-life planning. Below are four documents that are comparable to the Five Wishes Document:
When filling out the Five Wishes Document form, there are important guidelines to follow. Here’s a list of things you should and shouldn’t do:
Filling out and utilizing the Five Wishes Document form is an important step in ensuring that your healthcare preferences are respected in times of serious illness. Here are key takeaways to consider:
By taking the time to fill out the Five Wishes Document, individuals can ensure that their healthcare preferences are known and respected, providing comfort to themselves and their loved ones during challenging times.