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Contents

Form Specs

Fact Name Description
Living Will Five Wishes is a living will that addresses personal, emotional, and spiritual needs, in addition to medical wishes.
Health Care Agent This document allows you to designate a person to make health care decisions on your behalf if you are unable to do so.
State Validity Five Wishes is valid in the District of Columbia and 42 states, subject to each state’s specific legal requirements.
Ease of Use The form is designed to be easy to complete, requiring only simple actions like checking boxes or writing brief responses.

Dos and Don'ts

When filling out the Five Wishes Document form, it is essential to approach the process with care and consideration. Here are some important do's and don'ts to keep in mind:

  • Do clearly print your name and birthdate at the top of the document.
  • Do select a trusted person to make health care decisions on your behalf.
  • Do discuss your wishes with your chosen health care agent before finalizing the document.
  • Do ensure that the form is signed and dated according to your state’s requirements.
  • Don't rush through the form; take your time to think about each section carefully.
  • Don't choose someone as your health care agent who may have conflicts of interest, such as your doctor.
  • Don't forget to inform your family and your health care agent about your completed wishes.
  • Don't leave any sections blank; ensure all relevant areas are filled out completely.

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Common mistakes

  1. Incomplete Information: Failing to fill out all required fields, such as your name or birthdate, can render the document invalid.

  2. Choosing the Wrong Agent: Selecting someone who may not be available or capable of making decisions in a crisis can lead to complications.

  3. Not Discussing Wishes: Not having a conversation with your chosen health care agent about your wishes can create confusion when decisions need to be made.

  4. Ignoring State Requirements: Failing to check if your state recognizes the Five Wishes document can lead to legal issues.

  5. Not Revoking Previous Documents: Forgetting to destroy old living wills or advance directives can cause conflicts regarding your wishes.

  6. Leaving Out Important Details: Omitting specific preferences about medical treatments or comfort can lead to misunderstandings later.

  7. Using Incorrect Language: Misunderstanding terms or instructions on the form can result in a document that does not accurately reflect your wishes.

  8. Failing to Sign and Date: Not signing or dating the document can invalidate it, making it unenforceable.

  9. Not Informing Loved Ones: Not sharing your completed Five Wishes document with family members or your health care agent can lead to confusion during critical times.

Documents used along the form

The Five Wishes document is an important tool for individuals to express their healthcare preferences. Alongside this document, several other forms and documents may be utilized to ensure comprehensive planning for medical care and personal wishes. Below is a list of related documents often used in conjunction with the Five Wishes form.

  • Durable Power of Attorney for Health Care: This document allows an individual to appoint someone to make healthcare decisions on their behalf if they are unable to do so. It is a legal instrument that can specify the extent of the agent's authority.
  • Living Will: A living will outlines an individual's preferences regarding medical treatment in situations where they are unable to communicate their wishes. It typically focuses on end-of-life care and specific medical interventions.
  • Do Not Resuscitate (DNR) Order: This medical order indicates that a person does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest. It must be signed by a physician and is often included in a patient's medical records.
  • Advance Directive: An advance directive is a broader term that encompasses both living wills and durable powers of attorney for healthcare. It allows individuals to outline their healthcare preferences and appoint someone to make decisions on their behalf.
  • Illinois Application Firearm Form: A crucial document for those needing authorization to possess firearms in Illinois, addressing eligibility, fees, and personal disclosures. For more information, visit https://formsillinois.com.
  • Health Care Proxy: Similar to a durable power of attorney, a health care proxy designates a specific person to make healthcare decisions for someone when they are incapacitated. This document can be part of an advance directive.
  • Organ Donation Registration: This document allows individuals to express their wishes regarding organ donation after death. It can be registered through state registries or included in advance directive documents.

Using these documents together with the Five Wishes form can help ensure that an individual’s healthcare preferences are clearly communicated and respected. It is advisable to discuss these documents with family members and healthcare providers to ensure that everyone is aware of the individual's wishes.

Misconceptions

Misconceptions about the Five Wishes Document can lead to confusion and hesitation in making important health care decisions. Here are eight common misconceptions explained clearly.

  • Five Wishes is just a medical document. Many believe that Five Wishes is solely a legal document. In reality, it encompasses personal, emotional, and spiritual needs, making it unique compared to traditional living wills.
  • Five Wishes is only for the elderly. Some think that only older adults need to fill out this document. However, anyone 18 or older can benefit from it, regardless of age or health status.
  • Five Wishes is not legally binding. A common belief is that Five Wishes lacks legal validity. In fact, it is recognized as a valid advance directive in many states, provided it is properly completed and signed.
  • Choosing a health care agent is unnecessary. Some individuals feel that selecting a health care agent is not important. However, having someone designated to make decisions on your behalf can relieve family members from the burden of guessing your wishes during difficult times.
  • Five Wishes can only be used in certain states. Many assume that Five Wishes is only valid in a few states. While it is true that it meets specific legal requirements in 42 states and the District of Columbia, it can still serve as a guide for individuals in other states.
  • You cannot change your Five Wishes document. Some believe that once completed, the document cannot be altered. In reality, you can revoke or change your Five Wishes by filling out a new document and informing relevant parties.
  • Five Wishes is complicated to fill out. Many think that the form is overly complex. On the contrary, it is designed to be straightforward, requiring simple choices and a few sentences to express your wishes.
  • Health care providers will ignore Five Wishes. Some worry that health care professionals may not honor the document. However, most doctors and health care providers are trained to respect patients' wishes, regardless of how they are communicated.

Preview - 5 Wishes Document Form

FIVE

WISH S®

M Y W I S H F O R :

The Person I Want too Make Car1e Decisions for Me When I Can’t

The Kind of Medical Treat2ment I Want or Don’t Want

How Comfortable3 I Want to Be

How I Want People4 to Treat Me

What I Want My Loved5 Ones to Know

print your name

birthdate

Five Wishes

There are many things in life that are out of our hands. This Five Wishes document gives you a way to control somethingg very

important—how you are treated if you get seriously ill. It is ann easy-to- complete form that lets you say exactly what you want. Once it is filled out and properly signed it is valid under the laws off most states.

What Is Five Wishes?

Five Wishes is the first living will that talks about your personal, emotional and spiritual needs as well as your medical wishes. It lets you choose the person you want to make health care decisions for you if you are not able to make them for yourselff. Five Wishes

lets you say exactly how you wish to be

treated if you get seriously ill. It was written with the help of The American Bar

$VVRFLDWLRQ·V&RPPLVVLRQRQ/DZDQG$JLQJ DQGWKHQDWLRQ·VOHDGLQJH[SHUWVLQHQGRIOLIH FDUH,W·VDOVRHDV\WRXVH$OO\RXKDYHWRGRLV check a box, circle a direction, or write a few

sentences.

How Five Wishes Can Help You And Your Family

•

It lets

you talk with your family,

 

 

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frie

 

 

 

 

 

 

 

 

 

without knowing your wishes.

 

 

nds and doctor about how you

 

 

wantt

 

 

 

 

 

 

 

 

 

 

to be treated if you become

• You can know what your mom, dad,

 

 

seriou

 

 

 

 

 

 

 

 

 

sly ill.

 

 

 

 

spouse, or friend wants. You can be

•

 

Your family membe

rs will not have to

 

there for them when they need you

 

 

 

 

 

t. It protects them

most. You will understand what they

 

 

guess what you wan

 

 

 

ously ill, because

really want.

 

 

if you become seri

How Five Wishes Began

For 12 years, Jim Towey worked closely with Mother Teresa, and, for one year, he lived in a KRVSLFHVKHUDQLQ:DVKLQJWRQ'&,QVSLUHGE\ WKLVILUVWKDQGH[SHULHQFH0U7RZH\VRXJKWD way for patients and their families to plan ahead and to cope with serious illness. The result is

2Five Wishes and the response to it has been

RYHUZKHOPLQJ,WKDVEHHQIHDWXUHGRQ&11 DQG1%&·V7RGD\6KRZDQGLQWKHSDJHVRI Time and MoneyPDJD]LQHV1HZVSDSHUVKDYH called Five Wishes the first “living will with a heart and soul.” Today, Five Wishes is available in 27 languages.

Who Should Use Five Wishes

Five Wishes is for anyone 18 or older — married, single, parents, adult children, and friends. More than 19 million people of all ages have already used it. Because it

works so well, lawyers, doctors, hospitals and hospices, faith communities, employers, and retiree groups are handing outt this document.

Five Wishes States

If you live in the District of Columbia or one of the 42 states listed below, youu can use )LYH:LVKHVDQGKDYHWKHSHDFHRIPLQGWRNQRZWKDWLWVXEVWDQWLDOO\PHHWV\RXUVWDWH·V requirements under the law:

Alaska

Illinois

Montana

 

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Arizona

Iowa

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Arkansas

Kentucky

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Tennessee

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1HZ-HUVH\

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vermont

 

 

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Maine

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Virginia

 

 

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Maryland

 

 

 

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Washington

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Delaware

Massachusetts

 

 

 

 

 

 

 

 

 

West Virginia

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Florida

Michigan

 

 

 

 

 

 

 

Wisconsin

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Georgia

Minnesota

Oklahoma

 

 

 

Wyoming

Hawaii

Mississippi

 

 

 

 

 

 

 

 

 

 

 

 

Pennsylvania

 

 

 

 

 

Idaho

Missouri

 

 

 

 

 

 

 

 

Rhode Island

 

 

 

 

 

If your state is not one of the 42 states listed here, Five Wishes does not meet the technical UHTXLUHPHQWVLQWKHVWDWXWHVRI\RXUVWDWH6RVRPHGRFWRUVLQ\RXUVWDWHPD\EHUHOXFWDQW to honor Five Wishes. However, many people from states not on this list do complete Five :LVKHVDORQJZLWKWKHLUVWDWH·VOHJDOIRUP7KH\ILQGWKDW)LYH:LVKHVKHOSVWKHPH[SUHVV all that they want and provides a helpful guide to family members, friends, care givers and doctors. Most doctors and health care professionals know they need to listen to your wishes no matter how you express them.

How Do I Change To Five Wishes?

You may already have a living will or a durable power of attorney for health care. If you want to use Five Wishes instead, all you need to do is fill out and sign a new Five Wishes as directed. As soon as you sign it, it takes away any advance directive you had before. To make sure the right form is used, please do the following:

•

D

estroy all copies of your old living will

•

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or durable power of attorney for health

 

members, and doctor that you have

 

care. Or you can write “revoked” in large

 

filled out a new Five Wishes.

 

letters across the copy you have. Tell

 

Make sure they know about your

 

your lawyer if he or she helped prepare

 

new wishes.

 

those old forms for you. AND

 

 

3

WISH 1

The Person I Want To Make Health Care Decisions For Me

When I Can’t Make Them For Myself.

f I am no longer able to make my own health care

 

 

 

• My attending or treating doctor finds I am no

I decisions, this form names the person I choose to

 

 

 

 

longer able to make health ca

 

es, AND

 

 

 

 

re choic

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

make these choices for me. This person will be my

 

 

 

• Another health care profe

ssional agrees

t

hat

Health Care Agent (or other term that may be used in

 

 

 

 

this is true.

 

 

 

 

 

 

 

 

 

 

MPLE

my state, such as proxy, representative, or surrogate).

 

 

If my state has a different

 

w

ay of finding that I am not

 

This person will make my health care choices if both

 

 

able to make health c

 

are choices, then my state’s way

 

of these things happen:

 

 

 

should be followe

d.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Person I Choose As My Health Care Agent Is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Choice Name

 

 

Ph

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

one

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

If this person is not able or willing to make thesee choices for me, OR is divorced or legally separated from me, OR this person has died, then these people aree my next choices:

Second Choice Name

 

 

 

 

 

e

 

Third Choice Nam

 

 

 

 

 

 

 

 

Address

 

A

 

 

 

 

 

 

ddress

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Picking The R

 

Your Health Care Agent

 

ight Person To Be

 

 

 

 

 

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can make difficult

Agent should be at least 18 years or older (in

cares about you, and who

 

 

 

 

 

 

 

ily member may

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not be the best choice because they are too

 

 

•

Your health care provider, including the

 

 

 

 

 

 

 

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owner or operator of a health or residential

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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or community care facility serving you.

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ho is able to stand up for you so that your

 

 

 

 

 

 

 

 

 

 

 

 

wishes are followed. Also, choose someone who

 

 

•

An employee or spouse of an employee of

is likely to be nearby so that they can help when

 

 

 

 

your health care provider.

you need them. Whether you choose a spouse,

 

 

 

 

 

 

 

 

 

 

 

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Agent, make sure you talk about these wishes

 

 

 

 

more people unless he or she is your

and be sure that this person agrees to respect

 

 

 

 

spouse or close relative.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

I understand that my Health Care Agent can make health care decisions for me. I want my Agent to be able to do the

following: (Please cross out anything you don’t want your Agent to do that is listed below.)

•

Make choices for me about my medical care

‡

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or services, like tests, medicine, or surgery.

 

and personal files. If I need to sign my name to

 

This care or service could be to find out what my

 

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health problem is, or how to treat it. It can also

 

sign it for me.

 

include care to keep me alive. If the treatment or

•

Move me to another

 

 

 

 

 

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.

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______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If I Change My Mind About Having A Health Care Agent, I Will

•

Destroy all copies of this part of the

• Write the word “Revoked” in large

 

Five Wishes form. OR

letters across the name of each agent

• Tell someone, such as my doctor or

whose authority I want to cancel.

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family, that I want to cancel or change

 

 

 

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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.

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VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.

In A Coma And Not Expected Too Wake Up Or Recover:

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❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

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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 RUXQGHUVWDQGDQG,DPQRWH[SHFWHGWRJHWEHWWHUDQG OLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKHPRPHQWRI P\GHDWK&KRRVHoneRIWKHIROORZLQJ

❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

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In Another Condition Under Which I Do Not Wish To Be Kept Alive:

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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

________________________________________________________________________________________

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________________________________________________________________________________________

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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

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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

 

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

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_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

(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):

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•The individual appointed as (agent/proxy/

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•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

 

 

 

 

Signature of Witness #2

#1

 

 

 

 

 

 

 

 

 

 

Printed Name of Witn

 

 

 

 

 

Printed Name of Witness

ess

 

 

 

 

 

 

 

 

 

 

Address

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

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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10

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Key takeaways

Filling out the Five Wishes document can be an important step in ensuring your healthcare preferences are known and respected. Here are some key takeaways to consider:

  • Understand the Purpose: Five Wishes is designed to address not only medical decisions but also personal, emotional, and spiritual needs. It provides a comprehensive way to express your desires for end-of-life care.
  • Choose Your Health Care Agent Wisely: Select someone who knows you well and can advocate for your wishes. This person should be at least 18 years old and ideally someone who can be present when decisions need to be made.
  • Communicate Your Wishes: It’s essential to discuss your preferences with your family and your chosen health care agent. This ensures they understand your desires and can act accordingly if the need arises.
  • Legal Validity: Once completed and signed, the Five Wishes document is valid in most states. However, check if your state is among the 42 that recognize it to ensure compliance with local laws.
  • Revoking Previous Directives: If you decide to use Five Wishes instead of an existing living will or power of attorney, make sure to revoke the old documents. Destroy copies and inform relevant parties about your new wishes.
  • Accessible and Easy to Use: The form is straightforward, allowing you to check boxes, circle options, or write in your preferences. This simplicity makes it easier for anyone to express their wishes clearly.

By taking the time to complete the Five Wishes document, you empower yourself and your loved ones to make informed decisions during difficult times.

Similar forms

The Five Wishes document serves as a comprehensive guide for individuals to express their healthcare preferences and designate a decision-maker in the event they become unable to communicate their wishes. Several other documents serve similar purposes, each with its unique focus and structure. Below are eight documents that share similarities with the Five Wishes form:

  • Living Will: A living will outlines an individual's preferences for medical treatment in situations where they are unable to express their wishes, such as terminal illness or incapacitation. Like Five Wishes, it addresses healthcare decisions but is typically more focused on medical interventions alone.
  • Durable Power of Attorney for Healthcare: This document designates a specific person to make healthcare decisions on behalf of someone else if they are unable to do so. Similar to Five Wishes, it emphasizes the importance of having a trusted individual advocate for one's medical preferences.
  • Divorce Settlement Agreement: A Divorce Settlement Agreement is a critical document that outlines the mutual terms of the divorce between parties, covering aspects such as asset division, custody arrangements, and financial responsibilities. Utilizing resources like Forms Washington can simplify the process of creating this essential legal document.
  • Advance Directive: An advance directive is a broader term that includes both living wills and durable powers of attorney. It allows individuals to outline their healthcare preferences and appoint someone to make decisions for them, paralleling the comprehensive approach of Five Wishes.
  • Do Not Resuscitate (DNR) Order: A DNR order specifically instructs healthcare providers not to perform CPR if a patient stops breathing or their heart stops. While it focuses on a specific aspect of care, it aligns with the intent of Five Wishes by ensuring that a patient's wishes regarding life-sustaining treatment are respected.
  • POLST (Physician Orders for Life-Sustaining Treatment): A POLST form translates a patient's wishes regarding life-sustaining treatment into actionable medical orders. Like Five Wishes, it is intended for individuals with serious illnesses and ensures that their preferences are honored in medical emergencies.
  • Healthcare Proxy: A healthcare proxy is a person appointed to make medical decisions on someone’s behalf. This document is similar to the Health Care Agent designation in Five Wishes, emphasizing the importance of having a representative who understands the individual's values and wishes.
  • Personal Health Record: While not a legal document, a personal health record compiles an individual's medical history and preferences. It complements Five Wishes by providing healthcare providers with essential information about a patient's values and treatment preferences.
  • Funeral Planning Document: This document allows individuals to express their wishes regarding funeral arrangements and end-of-life preferences. While it focuses on post-death decisions, it parallels Five Wishes in that both documents empower individuals to communicate their desires regarding significant life events.