The Five Wishes Document is a unique form that allows individuals to express their personal, emotional, and spiritual needs regarding medical treatment in the event they cannot communicate their wishes. It empowers you to designate a trusted person to make health care decisions on your behalf and outlines your preferences for comfort and treatment. By filling out this straightforward form, you can ensure that your desires are known and respected during critical times.
Take control of your health care decisions by completing the Five Wishes Document today. Click the button below to get started.
Life is unpredictable, and while we cannot control every situation, we can prepare for the unexpected, especially regarding our health care decisions. The Five Wishes document empowers individuals to express their preferences regarding medical treatment and care when they cannot speak for themselves. This form addresses five critical areas: it designates a trusted person to make health care decisions on your behalf, outlines the specific medical treatments you desire or wish to avoid, details your comfort preferences, specifies how you want to be treated by caregivers, and conveys important messages to your loved ones. Designed to be straightforward and user-friendly, Five Wishes is recognized as a legal document in most states, providing peace of mind for both you and your family. It encourages open conversations about health care preferences, ensuring that your wishes are known and respected, thus alleviating the burden on family members during difficult times. With roots tracing back to the compassionate work of Jim Towey alongside Mother Teresa, Five Wishes has touched the lives of millions, making it a vital resource for anyone aged 18 and older. Whether you are single, married, or a parent, this document serves as a crucial tool for planning ahead and ensuring your voice is heard in times of need.
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 expressing your health care preferences. This form allows you to designate a person to make decisions on your behalf if you are unable to do so. It also covers your wishes regarding medical treatment, comfort, and how you want to be treated. Once completed and signed, the document is valid in most states, providing peace of mind for you and your loved ones.
The Five Wishes document is a living will that allows individuals to express their personal, emotional, and spiritual needs, in addition to their medical wishes. It empowers you to designate a person to make health care decisions on your behalf if you are unable to do so. This document is designed to ensure that your preferences regarding treatment and care are known and respected.
Anyone who is 18 years or older can use the Five Wishes document. This includes married individuals, single people, parents, adult children, and friends. The document is accessible to all and has been utilized by over 19 million people across various demographics.
The Five Wishes document facilitates open communication with your family regarding your health care preferences. By clearly outlining your wishes, your loved ones will not have to make difficult decisions without understanding your desires. This clarity can provide peace of mind during challenging times, allowing family members to support each other effectively.
Five Wishes is recognized in the District of Columbia and 42 states, including Alaska, Florida, and Virginia, among others. If you reside in a state not listed, the document may not meet that state's technical requirements. However, many individuals still complete Five Wishes alongside their state’s legal forms to ensure their wishes are communicated to family and health care providers.
If you currently have a living will or durable power of attorney for health care and wish to use Five Wishes instead, you can do so by filling out and signing the Five Wishes document. This new document will revoke any prior advance directives. It is essential to destroy all copies of the old documents and inform your health care agent and family members about your new wishes.
When selecting a health care agent, choose someone who understands your values and wishes. This person should be at least 18 years old and able to make difficult decisions on your behalf. It is important to select someone who is likely to be available when needed and who can advocate for your preferences in a medical setting.
Yes, you can make changes to your Five Wishes document. If you change your mind about your health care agent or any other aspect of your wishes, you must revoke the previous document by destroying it or marking it as revoked. Then, you can fill out a new Five Wishes document to reflect your updated preferences.
Failing to provide a full name and birthdate at the beginning of the form can lead to confusion about the identity of the individual making the wishes known.
Not specifying a Health Care Agent can result in a lack of clarity about who will make decisions on behalf of the individual if they are unable to do so.
Choosing a Health Care Agent who is not familiar with the individual's wishes can lead to decisions that do not reflect their true desires.
Omitting to discuss the wishes with the chosen agent can create misunderstandings about what the individual wants in a medical crisis.
Not reviewing the document periodically can result in outdated wishes that no longer align with the individual's current values or preferences.
Neglecting to sign the document properly can invalidate the wishes expressed, rendering the document ineffective.
Failing to inform family members and healthcare providers about the existence of the document can lead to confusion during critical moments.
Not crossing out any unwanted options in the form can lead to unintended choices being made by the Health Care Agent.
Leaving sections of the form blank can create ambiguity and uncertainty about specific wishes.
Not checking state-specific legal requirements can result in a document that does not meet the necessary criteria to be honored.
The Five Wishes document is a valuable tool for individuals looking to express their healthcare preferences in times of serious illness. Alongside this document, several other forms and documents can further clarify and support an individual's healthcare decisions. Below is a list of these commonly used documents.
These documents work together to ensure that your healthcare preferences are clearly communicated and legally binding. Utilizing them can provide peace of mind for you and your loved ones during difficult times.
The Advance Directive is a legal document that allows individuals to specify their healthcare preferences in case they become unable to communicate those wishes. Similar to the Five Wishes document, it empowers individuals to appoint a healthcare proxy, who will make medical decisions on their behalf. Advance Directives often focus primarily on medical treatment choices, such as life-sustaining measures, without delving into the emotional or spiritual aspects of care. This document ensures that healthcare providers and family members are aware of the patient's desires, thus minimizing confusion during critical times.
The Durable Power of Attorney for Healthcare is another document that shares similarities with the Five Wishes form. This document allows individuals to designate a trusted person to make healthcare decisions if they are incapacitated. While Five Wishes includes personal preferences regarding comfort and treatment, the Durable Power of Attorney focuses on the legal authority granted to the agent. This ensures that the appointed individual can act in accordance with the patient’s wishes, effectively bridging the gap between legal authority and personal care preferences.
The Living Will is a document that outlines specific medical treatments an individual does or does not want in the event of terminal illness or incapacitation. Like Five Wishes, it serves to communicate a person's healthcare preferences to family members and medical professionals. However, Living Wills are often more limited in scope, primarily addressing medical interventions rather than encompassing the broader emotional and spiritual needs that Five Wishes addresses. This document is crucial for ensuring that a person's wishes are honored when they can no longer speak for themselves.
The Do Not Resuscitate (DNR) Order is a specific medical directive that instructs healthcare providers not to perform CPR if a patient stops breathing or their heart stops. While Five Wishes provides a comprehensive overview of a person's healthcare preferences, a DNR focuses solely on resuscitation efforts. Both documents aim to honor a person's wishes in medical emergencies, but the DNR is more narrowly defined and typically requires a physician's signature to be valid.
The Medical Order for Life-Sustaining Treatment (MOLST) is a physician's order that details a patient's preferences regarding life-sustaining treatments. Similar to Five Wishes, MOLST is designed for individuals with serious health conditions who wish to communicate their treatment preferences clearly. However, MOLST is a medical order that must be signed by a healthcare provider, making it more authoritative in clinical settings. This ensures that healthcare teams are legally bound to follow the specified treatment preferences.
The Health Care Proxy is a document that allows individuals to appoint someone to make healthcare decisions on their behalf. This is akin to the Health Care Agent designation in Five Wishes. While both documents serve to empower a chosen individual to act in a patient’s best interests, the Health Care Proxy typically does not include the personal preferences regarding treatment and care that Five Wishes emphasizes. This distinction highlights the importance of combining legal authority with personal wishes for comprehensive healthcare planning.
The Personal Health Record (PHR) is a document that individuals maintain to track their health information, including medical history, medications, and treatment preferences. While not a directive like Five Wishes, a PHR can complement it by providing healthcare agents and providers with vital information about a patient's health status and preferences. This document serves as a useful tool for ensuring that all aspects of a person's healthcare wishes are communicated effectively, especially in emergency situations.
The Organ Donation Consent form is a document that allows individuals to express their wishes regarding organ donation after death. While Five Wishes includes preferences for end-of-life care and treatment, the Organ Donation Consent form specifically addresses the individual's desires regarding the donation of organs and tissues. Both documents aim to ensure that a person's wishes are respected, but they focus on different aspects of healthcare decision-making.
The Physician Orders for Scope of Treatment (POST) is a document that provides medical orders for patients with serious illnesses. Similar to MOLST, POST outlines specific medical interventions that a patient desires or wishes to avoid. While Five Wishes includes personal preferences and emotional considerations, POST is primarily focused on clinical orders that guide healthcare providers in delivering care. This document is essential for ensuring that patients receive treatment aligned with their wishes in critical situations.
When filling out the Five Wishes Document form, there are some important things to keep in mind. Here is a list of what you should and shouldn't do:
There are several misconceptions about the Five Wishes document that can lead to confusion. Understanding these misconceptions can help individuals make informed decisions about their end-of-life care. Here are five common misunderstandings:
The Five Wishes Document is a valuable tool that allows individuals to express their medical, emotional, and spiritual preferences in the event of a serious illness.
Filling out the form is straightforward. You simply check boxes, circle options, or write brief statements to convey your wishes.
Once completed and signed, the document is legally valid in most states, ensuring that your preferences are respected.
Choosing a Health Care Agent is a critical step. This person will make health care decisions on your behalf if you become unable to do so.
It is essential to communicate your wishes with your family and the designated Health Care Agent. This prevents confusion and ensures they can advocate for you effectively.
If you have an existing living will or durable power of attorney, completing the Five Wishes Document will revoke those previous documents once it is signed.