Fill Out a Valid 5 Wishes Document Form
The Five Wishes document serves as a vital tool for individuals seeking to express their healthcare preferences in a comprehensive manner. This form addresses five key areas: the designation of a health care agent, the type of medical treatment desired or refused, comfort preferences, treatment by others, and messages for loved ones. By allowing individuals to appoint someone they trust to make medical decisions on their behalf when they are unable to do so, the Five Wishes document empowers people to maintain a sense of control during challenging times. It also provides clarity on specific medical interventions one may wish to accept or decline, ensuring that personal values and beliefs are honored. Furthermore, the document emphasizes the importance of comfort and respectful treatment, fostering a compassionate approach to care. With its straightforward format, the Five Wishes document is designed to facilitate open discussions among family members and healthcare providers, minimizing the burden of decision-making during moments of crisis. Valid in many states, this living will not only addresses medical needs but also encompasses emotional and spiritual considerations, making it a holistic approach to end-of-life planning.
Common mistakes
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Incomplete Information: Many individuals forget to fill out all required fields, such as their name or birthdate. This can lead to delays or invalidation of the document.
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Choosing the Wrong Agent: Some people select a health care agent without considering their ability to make tough decisions. It’s essential to choose someone who understands your wishes and can advocate for you effectively.
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Not Discussing Wishes: Failing to communicate your preferences with the chosen agent and family members can create confusion. It’s vital to have open discussions about your health care desires.
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Ignoring State Requirements: Each state has specific laws regarding living wills. Individuals often overlook these requirements, which can render the document ineffective if not properly aligned with state laws.
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Neglecting to Sign: A common mistake is forgetting to sign the document. Without a signature, the Five Wishes document is not legally binding.
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Not Revoking Previous Documents: If a new Five Wishes document is created, individuals sometimes forget to revoke any prior living wills or health care directives. This can lead to conflicting directives.
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Overlooking Updates: Life circumstances change. Failing to revisit and update the Five Wishes document can result in outdated information, which may not reflect current desires.
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
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
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without knowing your wishes. |
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nds and doctor about how you |
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to be treated if you become |
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seriou |
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sly ill. |
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spouse, or friend wants. You can be |
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there for them when they need you |
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ously ill, because |
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if you become seri |
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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:
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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:
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estroy all copies of your old living will |
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or durable power of attorney for health |
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letters across the copy you have. Tell |
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your lawyer if he or she helped prepare |
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new wishes. |
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those old forms for you. AND |
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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 |
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• My attending or treating doctor finds I am no |
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I decisions, this form names the person I choose to |
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longer able to make health ca |
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re choic |
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make these choices for me. This person will be my |
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• Another health care profe |
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this is true. |
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my state, such as proxy, representative, or surrogate). |
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If my state has a different |
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This person will make my health care choices if both |
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The Person I Choose As My Health Care Agent Is: |
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First Choice Name |
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If this person is not able or willing to make thesee choices for me, OR is divorced or legally separated from me, OR this person has died, then these people aree my next choices:
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Picking The R |
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Your Health Care Agent |
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ight Person To Be |
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can make difficult |
Agent should be at least 18 years or older (in |
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cares about you, and who |
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ily member may |
&RORUDGR\HDUVRUROGHUDQGVKRXOGnot be: |
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decisions. A spouse or fam |
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not be the best choice because they are too |
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YHG6RPHWLPHVWKH\are the |
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owner or operator of a health or residential |
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or community care facility serving you. |
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ho is able to stand up for you so that your |
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wishes are followed. Also, choose someone who |
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your health care provider. |
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you need them. Whether you choose a spouse, |
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Agent, make sure you talk about these wishes |
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more people unless he or she is your |
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and be sure that this person agrees to respect |
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spouse or close relative. |
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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.)
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Make choices for me about my medical care |
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6HH DQGDSSURYHUHOHDVHRIP\PHGLFDOUHFRUGV |
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or services, like tests, medicine, or surgery. |
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and personal files. If I need to sign my name to |
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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 |
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sign it for me. |
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include care to keep me alive. If the treatment or |
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Move me to another |
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FDUHKDVDOUHDG\VWDUWHGP\+HDOWK&DUHAgent |
state to get the care I need |
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or to carry out m |
y wishes. |
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can keep it going or have it stopped. |
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•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$JHQWFDQKLUHDQ\NLQGRIKHDOWK care worker I may need to help me or take care of me. My Agent may also fire a health care worker, if needed.
•Make the decision to request, take away or not
JLYHPHGLFDOWUHDWPHQWVLQFOXGLQJDUWLILFLDOO\ provided food and water, andd any other treatments to keepp me alive.
•Authorize or refuse to authorize any medication or procedure needed to help with pain.
•Take any legal action needed to carry out my wishes.
•Donate useable organs or tissues of mine as allowed by law.
• Apply for Medicare, Medicaid, or other programs RULQVXUDQFHEHQHILWVIRUPH0\+HDOWK&DUH Agent can see my personal files, like bank records, to find out what is needed to fill out these forms.
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If I Change My Mind About Having A Health Care Agent, I Will
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Destroy all copies of this part of the |
• Write the word “Revoked” in large |
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Five Wishes form. OR |
letters across the name of each agent |
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• Tell someone, such as my doctor or |
whose authority I want to cancel. |
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6LJQP\QDPHRQWKDWSDJH |
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family, that I want to cancel or change |
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P\+HDOWK&DUH$JHQWOR |
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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
/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.
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In Case Of An Emergency
Iff you have a medical emergency and ambulance personnel arrive, they may look to see if you have a Do Not Resuscitate form or bracelet. Many states require a person to have a Do Not Resuscitate form filled out and
signed by a doctor. This form lets ambulance SHUVRQQHONQRZWKDW\RXGRQ·WZDQWWKHPWRXVH OLIHVXSSRUWWUHDWPHQWZKHQ\RXDUHG\LQJ3OHDVH check with your doctor to see if you need to have a Do Not Resuscitate form filled out.
6
Here is the kind of medical treatment that I want or don’t want in the four situations listed below. I want my Health Care Agent, my family, my doctors and other health care providers, my friends and all others to know these directions.
Close to death:
If my doctor and another health care professional both decide that I am likely to die within a short period of WLPHDQGOLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKH PRPHQWRIP\GHDWK&KRRVHoneRIWKHIROORZLQJ
❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW
❏ , GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.
❏,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to
VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.
In A Coma And Not Expected Too Wake Up Or Recover:
If my doctor and another health care professional both decide that I am in a coma from which I am not expected WRZDNHXSRUUHFRYHUDQG,KDYHEUDLQGDPDJHDQGOLIH support treatment would only delay the moment of my GHDWK&KRRVHoneRIWKHIROORZLQJ
❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW
❏ , GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.
❏,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to
VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.
Permanent And Severe Brain Damage And Not Expected To Recover:
If my doctor and another health care professional both decide that I have permanentt and severe brain damage,
(for example, I can open myy eyes, but I can not speak RUXQGHUVWDQGDQG,DPQRWH[SHFWHGWRJHWEHWWHUDQG OLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKHPRPHQWRI P\GHDWK&KRRVHoneRIWKHIROORZLQJ
❏ ,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW
❏ ,GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.
❏,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQWLIP\GRFWRU believes it could help. But I want my doctor to
VWRSJLYLQJPHOLIHVXSSRUWWUHDWPHQWLILWLVQRW helping my health condition or symptoms.
In Another Condition Under Which I Do Not Wish To Be Kept Alive:
If there is another condition under which I do not wish WRKDYHOLIHVXSSRUWWUHDWPHQW,GHVFULEHLWEHORZ,Q this condition, I believe that the costs and burdens of
OLIHVXSSRUWWUHDWPHQWDUHWRRPXFKDQGQRWZRUWKWKH benefits to me. Therefore, in this condition, I do not want OLIHVXSSRUWWUHDWPHQW)RUH[DPSOH\RXPD\ZULWH ´HQGVWDJHFRQGLWLRQµ7KDWPHDQVWKDW\RXUKHDOWKKDV gotten worse. You are not able to take care of yourself in DQ\ZD\PHQWDOO\RUSK\VLFDOO\/LIHVXSSRUWWUHDWPHQW will not help you recover. Please leave the space blank if \RXKDYHQRRWKHUFRQGLWLRQWRGHVFULEH
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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
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•The following person knows my funeral
wishes:.
If anyone asks how I want to be remembered, please say the following about me:
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If there is to bee a memorial service for me, I wish for this service to include the following
OLVWPXVLFVRQJVUHDGLQJVRURWKHUVSHFLILFUHTXHVWVWKDW\RXKDYH
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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
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Signing The Five Wishes Form
Please make sure you sign your Five Wishes form in the presence of the two witnesses.
I, _________________________________, ask that my family, my doctors, and other health care providers,
P\IULHQGVDQGDOORWKHUVIROORZP\ZLVKHVDVFRPPXQLFDWHGE\P\+HDOWK&DUH$JHQWLI,KDYHRQHDQGKH RUVKHLVDYDLODEOHRUDVRWKHUZLVHH[SUHVVHGLQWKLVIRUP7KLVIRUPEHFRPHVYDOLGZKHQ,DPXQDEOHWRPDNH decisions or speak for myself. If any part of this form cannot be legally followed, I ask that all other parts of this form be followed. I also revoke any health care advance directives I have made before.
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Witness Statement • (2 witnesses needed):
,WKHZLWQHVVGHFODUHWKDWWKHSHUVRQZKRVLJQHGRUDFNQRZOHGJHGWKLVIRUPKHUHDIWHU´SHUVRQµLVSHUVRQDOO\NQRZQWR PHWKDWKHVKHVLJQHGRUDFNQRZOHGJHGWKLV>+HDOWK&DUH$JHQWDQGRU/LYLQJ:LOOIRUPV@LQP\SUHVHQFHDQGWKDWKHVKH appears to be of sound mind and under no duress, fraud, or undue influence.
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•The individual appointed as (agent/proxy/
VXUURJDWHSDWLHQWDGYRFDWHUHSUHVHQWDWLYHE\ this document or his/her successor,
•7KHSHUVRQ·VKHDOWKFDUHSURYLGHULQFOXGLQJ RZQHURURSHUDWRURIDKHDOWKORQJWHUPFDUH or other residential or community care facility serving the person,
•$QHPSOR\HHRIWKHSHUVRQ·VKHDOWKFDUH provider,
•)LQDQFLDOO\UHVSRQVLEOHIRUWKHSHUVRQ·V health care,
•An employee of a life or health insurance provider for the person,
•Related to the person by blood, marriage, or adoption, and,
•To the best of my knowledge, a creditor of the person or entitled to any part of his/her estate under a will or codicil, by operation of law.
(Some states may have fewer rules about who may be a witness. Unless you know your state’s rules, please follow the above.)
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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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2QWKLVBBBBBGD\RIBBBBBBBBBBBBBBBBBBBBBBBWKHVDLGBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBDQGBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBNQRZQWRPHRUVDWLVIDFWRULO\SURYHQWREHWKHSHUVRQQDPHGLQWKH IRUHJRLQJLQVWUXPHQWDQGZLWQHVVHVUHVSHFWLYHO\SHUVRQDOO\DSSHDUHGEHIRUHPHD1RWDU\3XEOLFZLWKLQDQGIRUWKH6WDWHDQG&RXQW\DIRUHVDLGDQG acknowledged that they freely and voluntarily executed the same for the purposes stated therein.
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Documents used along the form
The Five Wishes document is an important tool for expressing your healthcare preferences. However, it often works best in conjunction with other legal forms and documents. Here’s a list of commonly used forms that can complement the Five Wishes document, helping to ensure your wishes are clearly communicated and legally recognized.
- Durable Power of Attorney for Health Care: This document allows you to appoint someone to make medical decisions on your behalf if you are unable to do so. It is a critical part of advance care planning.
- Living Will: A living will outlines your wishes regarding medical treatment in situations where you are unable to communicate your preferences. It specifically addresses end-of-life care and life-sustaining treatments.
- Do Not Resuscitate (DNR) Order: A DNR order is a medical directive that prevents healthcare providers from performing CPR if your heart stops or you stop breathing. This document is vital for those who do not wish to undergo resuscitation efforts.
- Mobile Home Bill of Sale: This document is crucial for anyone looking to transfer ownership of a mobile home. It serves as proof of the sale and outlines all relevant details, ensuring a smooth transaction. For more information, you can review the Mobile Home Bill of Sale.
- Health Care Proxy: Similar to a durable power of attorney, a health care proxy designates a person to make healthcare decisions for you. It is often used interchangeably with the durable power of attorney for health care.
- HIPAA Authorization: This form allows you to give permission for specific individuals to access your medical records. It is important for ensuring that your healthcare agent can obtain necessary information to make informed decisions.
- Advance Directive: An advance directive is a broader term that encompasses both living wills and durable powers of attorney for health care. It provides guidance to your loved ones and healthcare providers about your wishes regarding medical treatment.
- Personal Health Record: A personal health record is a document where you can keep track of your medical history, medications, allergies, and other important health information. It helps your healthcare agent and providers understand your health background.
Using these documents in conjunction with the Five Wishes can provide clarity and peace of mind. They ensure that your healthcare preferences are respected and that your loved ones are prepared to advocate for you when necessary.
Similar forms
The first document similar to the Five Wishes form is a Living Will. A Living Will is a legal document that outlines an individual's preferences regarding medical treatment in situations where they are unable to communicate their wishes. Like the Five Wishes, it allows individuals to specify the types of medical interventions they do or do not want, particularly in end-of-life scenarios. Both documents aim to relieve family members from making difficult decisions during emotionally charged times.
A Durable Power of Attorney for Health Care is another document that parallels the Five Wishes. This document designates a person to make health care decisions on behalf of someone else if they become incapacitated. While Five Wishes combines medical and personal preferences, the Durable Power of Attorney focuses primarily on appointing a trusted individual to make decisions, which can include adhering to the preferences outlined in Five Wishes.
The Advance Directive is also similar to Five Wishes. An Advance Directive is a broader term that encompasses both Living Wills and Durable Powers of Attorney. It serves as a guideline for medical professionals and family members about a person's health care preferences. Like Five Wishes, it is intended to ensure that an individual's wishes are respected when they cannot voice them.
The Texas RV Bill of Sale form is essential for anyone looking to formalize the sale or purchase of a recreational vehicle, ensuring clarity and legal protection for both the buyer and seller. By documenting all details of the transaction, including the vehicle's specifics and the parties involved, this form eliminates potential disputes while providing necessary records for future registration and taxation. For more information regarding this important document, visit https://autobillofsaleform.com/rv-bill-of-sale-form/texas-rv-bill-of-sale-form.
The Physician Orders for Life-Sustaining Treatment (POLST) form shares similarities with Five Wishes as well. POLST is designed for individuals with serious illnesses and provides specific medical orders regarding treatment preferences. While Five Wishes focuses on personal values and emotional needs, POLST provides actionable medical instructions, making it a practical complement to the broader wishes expressed in Five Wishes.
The Health Care Proxy is another document akin to Five Wishes. This form allows individuals to appoint someone to make health care decisions on their behalf. Similar to the Durable Power of Attorney, the Health Care Proxy emphasizes the importance of having a trusted person who understands and can advocate for the individual's wishes, aligning closely with the decision-making aspect of Five Wishes.
An Ethical Will is a less formal document that shares the personal expression aspect of Five Wishes. While it does not have legal standing, an Ethical Will allows individuals to convey their values, beliefs, and personal wishes to loved ones. This document complements Five Wishes by providing a space for emotional and spiritual reflections that may not be covered in more legalistic forms.
The Do Not Resuscitate (DNR) order is another document that aligns with the intent of Five Wishes. A DNR order specifically instructs medical personnel not to perform CPR if a person stops breathing or their heart stops. While Five Wishes addresses a broader range of health care preferences, a DNR is a specific directive that can be included within the wishes outlined in Five Wishes.
The Statement of Wishes is also similar to Five Wishes. This document allows individuals to outline their preferences regarding end-of-life care and other health-related matters. Like Five Wishes, it encourages open communication with family members and healthcare providers about what an individual values most in their care.
The Advance Care Planning Toolkit is a comprehensive resource that includes various forms and documents, including those similar to Five Wishes. It provides guidance on how to articulate health care preferences and make informed decisions. This toolkit emphasizes the importance of planning ahead, much like Five Wishes, which seeks to empower individuals to express their desires regarding medical treatment.
Finally, the Medical Directive is another document that shares common ground with Five Wishes. A Medical Directive outlines specific health care preferences and can include instructions about life-sustaining treatments. Like Five Wishes, it serves to inform healthcare providers and family members about the individual's wishes, ensuring that their preferences are honored during critical times.
Dos and Don'ts
When filling out the Five Wishes Document form, it is essential to approach the process thoughtfully. Here are five things you should and shouldn't do:
- Do carefully read each section of the form to understand what is being asked.
- Do choose a health care agent who knows your wishes and can advocate for you.
- Do discuss your choices with family members to ensure they understand your preferences.
- Do sign and date the form in the presence of witnesses, if required by your state.
- Do keep a copy of the completed document in a safe place and share it with your health care agent.
- Don't rush through the form; take your time to reflect on your wishes.
- Don't choose someone as your health care agent who is not supportive of your decisions.
- Don't leave any sections blank; provide as much information as possible.
- Don't forget to revoke any previous advance directives if you are replacing them with this document.
- Don't assume that verbal instructions are enough; always put your wishes in writing.
Key takeaways
Here are key takeaways regarding the use of the Five Wishes Document form:
- Purpose: The Five Wishes Document allows individuals to express their medical, emotional, and spiritual preferences for care in case they become seriously ill.
- Eligibility: Anyone aged 18 or older can fill out the Five Wishes Document, including married individuals, singles, and adult children.
- Health Care Agent: The form allows you to designate a Health Care Agent, the person who will make medical decisions on your behalf if you are unable to do so.
- Ease of Use: The document is designed to be straightforward, requiring users to check boxes, circle options, or write brief statements.
- Legal Validity: Once completed and signed, the Five Wishes Document is recognized as a valid advance directive in most states, including the District of Columbia and 42 other states.
- Communication Tool: Filling out this document helps facilitate discussions with family members and healthcare providers about your wishes, reducing confusion during difficult times.
- Revocation: If you decide to change your Health Care Agent or your wishes, you can revoke the previous document by destroying copies or marking them as revoked.
How to Use 5 Wishes Document
Filling out the Five Wishes Document is an important step in ensuring your healthcare preferences are known and respected. This guide will help you complete the form accurately and effectively.
- Begin by printing your name and birthdate at the top of the form.
- Identify the person you want to make healthcare decisions for you when you can’t. This person will be your Health Care Agent. Write their name, phone number, and address in the designated area.
- Choose your second and third choices for a Health Care Agent in case your first choice is unavailable. Include their names, phone numbers, and addresses.
- Indicate what you want your Health Care Agent to be able to do. Review the list of powers and cross out any that you do not want them to have.
- Consider any changes or limitations to your Health Care Agent’s powers. Write these in the space provided.
- If you change your mind about having a Health Care Agent, note that you will destroy all copies of this part of the Five Wishes form and inform someone, like your doctor or family, about the cancellation.
- Sign and date the form to validate it. Ensure that you follow any additional state-specific requirements, if applicable.
Once you have completed the form, keep a copy for your records and share it with your chosen Health Care Agent and family members. This will ensure that everyone is aware of your wishes and can act accordingly when needed.