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Fill a Valid 5 Wishes Document Form

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 of a serious illness. It empowers you to designate a trusted person to make healthcare decisions on your behalf and outlines your preferences for treatment and comfort. By completing this straightforward document, you can ensure your wishes are known and respected when it matters most.

Ready to take control of your healthcare decisions? Fill out the Five Wishes form by clicking the button below.

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Contents

In a world where uncertainty often looms over our health and well-being, the Five Wishes document offers a vital tool for individuals to express their medical and personal preferences in the event of a serious illness. This comprehensive form allows users to designate a trusted person to make healthcare decisions on their behalf when they are unable to do so themselves. It covers essential aspects such as the type of medical treatment one desires or wishes to avoid, the level of comfort sought during care, and the manner in which one prefers to be treated by healthcare providers and loved ones. Additionally, it provides space for individuals to convey important messages to their family members, ensuring that their wishes are known and respected. Designed to be user-friendly, the Five Wishes document can be completed with simple checkboxes, circles, or written notes, making it accessible for everyone. Valid in many states, this document not only addresses medical needs but also emphasizes emotional and spiritual considerations, reflecting a holistic approach to end-of-life care. Originating from the experiences of Jim Towey, who worked alongside Mother Teresa, Five Wishes has gained recognition for its compassionate approach, earning accolades as the "living will with a heart and soul." With over 19 million users and available in multiple languages, this form serves as a critical resource for anyone aged 18 and older, empowering individuals to take charge of their healthcare decisions and communicate their preferences clearly.

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Similar forms

Living Will: Similar to the Five Wishes document, a living will outlines a person's preferences regarding medical treatment in situations where they are unable to communicate their wishes. Both documents allow individuals to express their desires for end-of-life care.
Durable Power of Attorney for Health Care: This document designates a specific individual to make health care decisions on behalf of another person if they become incapacitated. Like Five Wishes, it emphasizes the importance of appointing a trusted person to advocate for one's medical preferences.
WC-200A Georgia Form: This form is essential for requesting a change of physician or additional treatment in workers' compensation cases. For more information, visit georgiapdf.com/wc-200a-georgia/.
Advance Directive: An advance directive is a broader term that encompasses both living wills and durable powers of attorney for health care. It serves as a legal document that communicates a person’s healthcare preferences, similar to the intentions expressed in Five Wishes.
Do Not Resuscitate (DNR) Order: A DNR order specifically instructs medical personnel not to perform CPR if a patient stops breathing or their heart stops. While Five Wishes includes broader medical treatment preferences, both documents reflect a person's wishes regarding life-sustaining treatment.
Health Care Proxy: A health care proxy is a legal document that appoints someone to make medical decisions on behalf of another person. Like Five Wishes, it focuses on ensuring that an individual's health care choices are respected when they cannot speak for themselves.
POLST (Physician Orders for Life-Sustaining Treatment): POLST is a medical order that outlines a patient’s preferences for treatment in emergencies. Similar to Five Wishes, it translates a person's wishes into actionable medical orders for healthcare providers.
Personal Health Care Plan: This document may include a person’s medical history, treatment preferences, and care goals. While it may not be legally binding like Five Wishes, it serves as a guide for family members and healthcare providers about an individual's wishes regarding their health care.

Document Example

FIVE

WISH S®

M Y W I S H F O R :

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

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

How Comfortable3 I Want to Be

How I Want People4 to Treat Me

What I Want My Loved5 Ones to Know

print your name

birthdate

Five Wishes

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

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

What Is Five Wishes?

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

lets you say exactly how you wish to be

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

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

sentences.

How Five Wishes Can Help You And Your Family

•

It lets

you talk with your family,

WKH\ZRQ·WKDYHWRPDNHKDUGFKRLFHV

frie

without knowing your wishes.

nds and doctor about how you

wantt

to be treated if you become

• You can know what your mom, dad,

seriou

sly ill.

spouse, or friend wants. You can be

•

Your family membe

rs will not have to

there for them when they need you

t. It protects them

most. You will understand what they

guess what you wan

ously ill, because

really want.

if you become seri

How Five Wishes Began

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

2Five Wishes and the response to it has been

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

Who Should Use Five Wishes

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

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

Five Wishes States

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

Alaska

Illinois

Montana

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Arizona

Iowa

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6RXWK'DNRWD

Arkansas

Kentucky

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Tennessee

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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	•	7HOO\RXU+HDOWK&DUH$JHQWIDPLO\
	or durable power of attorney for health			members, and doctor that you have
	care. Or you can write “revoked” in large			filled out a new Five Wishes.
	letters across the copy you have. Tell			Make sure they know about your
	your lawyer if he or she helped prepare			new wishes.
	those old forms for you. AND

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

make these choices for me. This person will be my

• Another health care profe

ssional agrees

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

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

The Person I Choose As My Health Care Agent Is:

First Choice Name

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

Third Choice Nam

Address

ddress

City/State/Zip

Phone

Picking The R

Your Health Care Agent

ight Person To Be

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DQGIROORZ\RXUZLVKHV<RXU+HDOWK&DUH

can make difficult

Agent should be at least 18 years or older (in

cares about you, and who

ily member may

&RORUDGR\HDUVRUROGHUDQGVKRXOGnot be:

decisions. A spouse or fam

not be the best choice because they are too

•

Your health care provider, including the

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owner or operator of a health or residential

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or community care facility serving you.

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.

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

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

•	Make choices for me about my medical care		6HH DQGDSSURYHUHOHDVHRIP\PHGLFDOUHFRUGV
	or services, like tests, medicine, or surgery.		and personal files. If I need to sign my name to
	This care or service could be to find out what my		JHWDQ\RIWKHVHILOHVP\+HDOW				$JHQWFDQ
	This care or service could be to find out what my		JHWDQ\RIWKHVHILOHVP\+HDOW			K&DUH	$JHQWFDQ
	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	•	Move me to another		state to get the care I need
	FDUHKDVDOUHDG\VWDUWHGP\+HDOWK&DUHAgent		or to carry out m	y wishes.
	can keep it going or have it stopped.		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.
• Tell someone, such as my doctor or		6LJQP\QDPHRQWKDWSDJH
	family, that I want to cancel or change	6LJQP\QDPHRQWKDWSDJH
	family, that I want to cancel or change
	P\+HDOWK&DUH$JHQWOR

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.

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

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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

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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

________________________________________________________________________________________

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.

WISH 5

My Wish For What I Want My Loved Ones To Know.

(Please cross out anything that you don’t agree with.)

•I wish to have my family and friends know that I love them.

•I wish to be forgiven for the times I have hurt my family, friends, and others.

•I wish to have my family, friends and others know that I forgive them for when they may have hurt me in my life.

•I wish for my family and friends to know that I do not fear death itself. I think it is not the end, but a new beginning for me.

•I wish for all of my family members to make peace with each other before my death, if they can.

•I wish for my family and friends to think about what I was like before I became seriously ill. I want them too remember me in this way after my death.

•I wish for my family and friends and caregivers to respect my wishes even if

WKH\GRQ·WDJUHHZLWKWKHP

•I wish for my family and friends to look at my dying as a time of personal growth for everyone, including me. This will help me livee a meaningful life in my final days.

•I wish for my family and friends to get counseling if they have trouble with my death. I want memories of my life to give

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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

OLVWPXVLFVRQJVUHDGLQJVRURWKHUVSHFLILFUHTXHVWVWKDW\RXKDYH

_________________________________________________________________________________

(Please use the space below for any other wishes. For example, you may want to donate any or all parts of your body when you die. You may also wish to designate a charity to receive memorial contributions. Please attach a VH DUDWHVKHHWRI D HULI\RXQHHGPRUHVSDFH

______________________________________________________________________________________

Signing The Five Wishes Form

Please make sure you sign your Five Wishes form in the presence of the two witnesses.

I, _________________________________, ask that my family, my doctors, and other health care providers,

P\IULHQGVDQGDOORWKHUVIROORZP\ZLVKHVDVFRPPXQLFDWHGE\P\+HDOWK&DUH$JHQWLI,KDYHRQHDQGKH RUVKHLVDYDLODEOHRUDVRWKHUZLVHH[SUHVVHGLQWKLVIRUP7KLVIRUPEHFRPHVYDOLGZKHQ,DPXQDEOHWRPDNH decisions or speak for myself. If any part of this form cannot be legally followed, I ask that all other parts of this form be followed. I also revoke any health care advance directives I have made before.

Signature:		___
Address:
Phone:	Date:		__

Witness Statement • (2 witnesses needed):

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

,DOVRGHFODUHWKDW,DPRYHU\HDUVRIDJHDQGDP127

•The individual appointed as (agent/proxy/

VXUURJDWHSDWLHQWDGYRFDWHUHSUHVHQWDWLYHE\ this document or his/her successor,

•7KHSHUVRQ·VKHDOWKFDUHSURYLGHULQFOXGLQJ RZQHURURSHUDWRURIDKHDOWKORQJWHUPFDUH or other residential or community care facility serving the person,

•$QHPSOR\HHRIWKHSHUVRQ·VKHDOWKFDUH provider,

•)LQDQFLDOO\UHVSRQVLEOHIRUWKHSHUVRQ·V health care,

•An employee of a life or health insurance provider for the person,

•Related to the person by blood, marriage, or adoption, and,

•To the best of my knowledge, a creditor of the person or entitled to any part of his/her estate under a will or codicil, by operation of law.

(Some states may have fewer rules about who may be a witness. Unless you know your state’s rules, please follow the above.)


Signature of Witness				Signature of Witness #2
Signature of Witness			#1	Signature of Witness #2

Printed Name of Witn				Printed Name of Witness
Printed Name of Witn		ess		Printed Name of Witness

Address				Address

				Phone
	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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Form Specs

Fact Name	Details
Purpose	The Five Wishes document allows individuals to outline their medical, personal, and emotional preferences for care when they are unable to communicate those wishes themselves.
First Living Will	Five Wishes is recognized as the first living will that addresses not only medical decisions but also personal and spiritual needs.
Health Care Agent	Individuals can designate a Health Care Agent to make health care decisions on their behalf if they are unable to do so.
Easy to Complete	The form is designed to be user-friendly, requiring individuals to check boxes, circle options, or write brief notes to express their wishes.
Validity	Once properly signed, Five Wishes is valid in most states, provided it meets state-specific legal requirements.
State-Specific Requirements	In states where Five Wishes is recognized, it must comply with local laws regarding advance directives.
Widespread Use	Over 19 million people have utilized Five Wishes, making it a popular choice among various demographics, including families and healthcare providers.
Changing Previous Directives	Filling out and signing a new Five Wishes document revokes any previous living wills or advance directives.
Language Availability	Five Wishes is available in 27 different languages, ensuring accessibility for diverse populations.
Origin	Jim Towey, inspired by his experiences with Mother Teresa, developed Five Wishes to help individuals and families prepare for serious illnesses.

Crucial Questions on This Form

What is the Five Wishes document?

The Five Wishes document is a legal form that allows individuals to express their personal, emotional, and spiritual needs alongside their medical wishes. It is designed for those who want to ensure their preferences are known and respected in the event they become seriously ill and cannot communicate their wishes. The document outlines who will make healthcare decisions on your behalf, the type of medical treatment you desire or wish to avoid, how comfortable you want to be, how you wish to be treated, and what you want your loved ones to know.

Who should complete the Five Wishes document?

Anyone who is 18 years or older can complete the Five Wishes document. This includes married individuals, single adults, parents, adult children, and friends. It is particularly beneficial for anyone who wants to ensure their healthcare preferences are communicated clearly to family members and healthcare providers. Over 19 million people have utilized this document, demonstrating its widespread acceptance and importance.

How does Five Wishes differ from a traditional living will?

Unlike a traditional living will, which typically focuses solely on medical treatment preferences, Five Wishes incorporates personal, emotional, and spiritual needs. It allows individuals to specify not just the medical care they want or do not want, but also how they wish to be treated by caregivers and loved ones. This holistic approach ensures that the document addresses the full spectrum of a person's wishes during a serious illness.

How can I change my existing advance directive to Five Wishes?

If you currently have a living will or durable power of attorney for healthcare and wish to switch to Five Wishes, you can do so by filling out and signing the Five Wishes document. Once signed, it automatically revokes any previous advance directives. It is crucial to destroy all copies of your old documents and inform your healthcare agent, family members, and doctor about your new wishes to avoid any confusion in the future.

In which states is Five Wishes valid?

Five Wishes is valid in the District of Columbia and 42 states across the United States. It is essential to ensure that your state recognizes the document as meeting its legal requirements. If you reside in a state not listed among those that accept Five Wishes, you may still complete the document, but it may not have the same legal standing. Many individuals in such states still find value in using Five Wishes as a guide for discussions with family and healthcare providers.

What are the benefits of using Five Wishes for my family?

Using Five Wishes can significantly alleviate the burden on family members during difficult times. It provides clear guidance on your preferences, reducing the need for them to make challenging decisions without knowing your wishes. This document encourages open conversations about healthcare preferences, ensuring that loved ones can support you in the way you desire. It fosters understanding and respect among family members, ultimately leading to better emotional support during a crisis.

Documents used along the form

When considering your health care preferences, it’s essential to have a comprehensive plan in place. The Five Wishes document is a great start, but there are other important forms and documents that can complement it. Here’s a brief overview of some of those documents.

Living Will: This document specifies your wishes regarding medical treatment in situations where you are unable to communicate your decisions. It typically focuses on end-of-life care and the types of medical interventions you do or do not want.
Durable Power of Attorney for Health Care: This form designates someone to make health care decisions on your behalf if you are incapacitated. Unlike a living will, it can cover a broader range of health care choices.
Notice to Quit Form: The Ohio Notice to Quit form is vital for landlords who need to inform tenants about vacating the premises due to lease violations, such as non-payment of rent. For more information, you can visit All Ohio Forms.
Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR if your heart stops or you stop breathing. It must be signed by a physician and is often kept in your medical records.
Health Care Proxy: Similar to a durable power of attorney, this document allows you to appoint someone to make medical decisions for you. It can be used in conjunction with a living will.
Organ Donation Registration: This document indicates your wishes regarding organ donation after your death. It can be part of your driver’s license or a separate form.
Advance Directive: This is a general term that encompasses both living wills and durable powers of attorney. It outlines your preferences for medical treatment and appoints someone to make decisions for you.
Physician Orders for Life-Sustaining Treatment (POLST): This form translates your wishes regarding treatment into actionable medical orders. It is typically used for those with serious illnesses or advanced age.
Emergency Medical Information Form: This document provides critical health information to emergency responders, including allergies, current medications, and existing medical conditions.
Family Communication Plan: This informal document outlines how you want your family to communicate about your health care wishes. It can include who should be contacted and how decisions should be made.

Having these documents in place can provide peace of mind for you and your loved ones. It ensures that your wishes are known and respected, especially during challenging times. Take the time to discuss these options with your family and health care providers to create a plan that reflects your values and preferences.

Misconceptions

Here are eight common misconceptions about the Five Wishes Document form:

It is only for the elderly. Many believe that Five Wishes is only relevant for older adults. In reality, anyone aged 18 or older can benefit from this document, regardless of age or health status.
It is legally binding in all states. While Five Wishes is valid in most states, it does not meet the legal requirements in every state. It’s essential to verify its acceptance based on local laws.
It replaces a will. Some think that Five Wishes serves as a substitute for a will. However, it specifically addresses health care preferences and does not cover asset distribution after death.
It is complicated to fill out. Many assume that completing the form is difficult. In fact, Five Wishes is designed to be user-friendly, requiring only simple choices and brief explanations.
It only addresses medical decisions. While Five Wishes does cover medical treatment preferences, it also encompasses emotional, personal, and spiritual needs, making it a holistic approach to end-of-life care.
Once completed, it cannot be changed. Some believe that the document is permanent once signed. In truth, individuals can revoke or modify their wishes at any time by following the proper steps.
It is only necessary if you are terminally ill. Many think that Five Wishes is only relevant for those with terminal conditions. However, it is beneficial for anyone who wants to ensure their health care preferences are honored in any serious situation.
Healthcare providers will automatically know your wishes. Some assume that doctors and hospitals will inherently understand a patient’s desires. Without a formal document like Five Wishes, there may be confusion or miscommunication regarding treatment preferences.