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Homepage Fill a Valid 5 Wishes Document Form

Misconceptions

  • Five Wishes is only for elderly people. Many believe that Five Wishes is designed solely for seniors. In reality, it is intended for anyone 18 or older, regardless of age or health status.
  • Five Wishes is a legal document only in certain states. While it is true that Five Wishes must meet specific legal requirements in different states, it is still a useful tool for expressing wishes in states where it may not be legally binding.
  • Filling out Five Wishes is complicated. Some think that completing the form is difficult. In fact, it is designed to be straightforward, requiring only simple choices and a few written sentences.
  • Five Wishes replaces all other legal documents. This document does not automatically revoke other advance directives unless explicitly stated. It is essential to destroy old documents to avoid confusion.
  • My family will know my wishes without Five Wishes. Many people assume their loved ones can guess their preferences. However, having a written document ensures clarity and prevents misunderstandings during difficult times.
  • Five Wishes is only about medical decisions. While it includes medical preferences, it also addresses personal, emotional, and spiritual needs, making it a comprehensive guide for care.
  • Once I fill it out, I cannot change it. Some believe that after completing Five Wishes, they cannot make updates. In reality, you can change your wishes at any time by filling out a new form and informing relevant parties.

Steps to Writing 5 Wishes Document

Filling out the Five Wishes document is a straightforward process that allows you to express your healthcare preferences. By completing this form, you ensure that your wishes are known and respected in case you cannot communicate them yourself. Here’s how to fill it out step-by-step.

  1. Begin by printing your name and birthdate at the top of the form.
  2. In the section titled “The Person I Want to Make Health Care Decisions for Me When I Can’t,” write the name of your chosen Health Care Agent. This should be someone you trust to make decisions on your behalf.
  3. Provide the phone number and address of your Health Care Agent, including city, state, and zip code.
  4. If your first choice is unable to act, list two additional choices in the designated areas, including their names, phone numbers, and addresses.
  5. Next, indicate what kind of medical treatment you want or don’t want. Be specific about any procedures or interventions you wish to accept or decline.
  6. In the section about comfort, describe how comfortable you want to be in various situations, such as pain management or end-of-life care.
  7. State how you want people to treat you during your care. This could include preferences about communication, emotional support, or privacy.
  8. Finally, share what you want your loved ones to know. This is a chance to express your thoughts and feelings regarding your care and wishes.
  9. Once you have completed the form, sign it at the bottom to validate your wishes.
  10. Make copies of the signed document and distribute them to your Health Care Agent, family members, and healthcare providers.

After you’ve filled out and signed the form, it’s important to keep the conversation going with your loved ones and healthcare providers. Make sure they understand your wishes and have access to the document. This proactive approach helps ensure that your preferences are honored when it matters most.

Common mistakes

Filling out the Five Wishes document is an important step in ensuring that your healthcare preferences are honored. However, many people make mistakes that can lead to confusion or invalidation of their wishes. One common mistake is not clearly identifying the person chosen as the Health Care Agent. It is essential to provide complete and accurate contact information, including their phone number and address. Omitting this information can create challenges in communication when decisions need to be made.

Another frequent error is failing to discuss the document with the chosen Health Care Agent. This conversation is crucial, as it ensures that the agent understands your wishes and is willing to advocate for them. Without this discussion, your agent may not be prepared to make difficult decisions on your behalf. Additionally, some individuals neglect to specify their preferences regarding medical treatments. It is vital to articulate your desires clearly, including any treatments you wish to refuse.

People often overlook the importance of signing and dating the document. An unsigned or undated form may not be considered valid under state law. Furthermore, failing to inform family members and healthcare providers about the completed document can lead to misunderstandings during critical times. It is advisable to share this information with those who may be involved in your care.

Another mistake is not reviewing the document periodically. As circumstances change, so might your wishes. Regularly revisiting the Five Wishes document ensures that it reflects your current preferences. Additionally, some individuals mistakenly assume that the Five Wishes document is universally accepted. It is essential to confirm that it meets the legal requirements in your state, as some states may have specific regulations regarding advance directives.

Lastly, people sometimes forget to destroy old versions of advance directives when creating a new Five Wishes document. Keeping outdated documents can lead to confusion among family members and healthcare providers about which wishes to follow. Ensuring that only the most current document is accessible helps avoid potential conflicts.

Form Data

Fact Name Fact Description
Document Purpose The Five Wishes document allows individuals to express their medical, emotional, and spiritual preferences for care if they become seriously ill.
First Living Will Five Wishes is recognized as the first living will that addresses personal and emotional needs alongside medical wishes.
Health Care Agent The document enables you to designate a Health Care Agent to make medical decisions on your behalf if you cannot do so yourself.
Ease of Use Filling out Five Wishes is straightforward. It requires checking boxes, circling options, or writing brief statements.
Widespread Adoption Over 19 million people have utilized Five Wishes, making it a widely accepted tool for advance care planning.
State Validity Five Wishes is valid in 42 states and the District of Columbia, provided it meets state-specific legal requirements.
Governing Laws Each state has its own laws governing advance directives. Check local regulations to ensure compliance.
Changing Previous Directives Signing Five Wishes revokes any previous living wills or durable powers of attorney for health care.
Communication Tool This document encourages discussions with family and friends about health care preferences, reducing uncertainty during critical times.
Multilingual Availability Five Wishes is available in 27 languages, making it accessible to a diverse population.

Frequently Asked Questions

  1. What is the Five Wishes document?

    The Five Wishes document is a unique form that allows individuals to express their personal, emotional, and spiritual needs regarding medical treatment and care. It serves as a living will, detailing how you want to be treated if you become seriously ill. This document also allows you to designate a person to make health care decisions on your behalf if you are unable to do so.

  2. Who should consider using Five Wishes?

    Anyone aged 18 or older can benefit from using Five Wishes. This includes married individuals, singles, parents, adult children, and friends. Over 19 million people have utilized this document, and it is widely accepted by healthcare professionals, hospitals, and legal entities.

  3. 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 encompasses emotional and spiritual needs as well. It provides a more comprehensive approach to end-of-life care, allowing individuals to express how they want to be treated in various aspects, not just medically.

  4. How do I complete the Five Wishes document?

    Completing the Five Wishes document is straightforward. You simply fill out the form by checking boxes, circling options, or writing brief responses. Once you’ve filled it out, sign it to make it legally valid in most states. Make sure to share your completed document with your designated health care agent and family members.

  5. What happens if I change my mind about my health care agent?

    If you decide to change your health care agent, you can do so by destroying all copies of the previous Five Wishes document and informing your family and healthcare provider about the change. You can also write “Revoked” across the name of the previous agent on any copies you may have.

  6. Is Five Wishes legally valid in my state?

    Five Wishes is legally valid in the District of Columbia and 42 states. If you live in one of these areas, the document meets the necessary legal requirements. However, if your state is not listed, it may not fulfill specific legal criteria, so it’s essential to check local laws or consult with a legal professional.

  7. Can my family members override my Five Wishes?

    Your family members should respect your wishes as outlined in the Five Wishes document. However, there may be situations where they feel compelled to act differently based on emotional circumstances. This is why it’s crucial to communicate your wishes clearly to your loved ones.

  8. How can Five Wishes help my family?

    Five Wishes alleviates the burden on family members during difficult times. By clearly outlining your preferences, it prevents them from having to make tough decisions without knowing what you would have wanted. This clarity can foster peace of mind and reduce conflict during emotionally charged situations.

  9. What should I do with my completed Five Wishes document?

    Once completed, keep the original document in a safe but accessible place. Share copies with your health care agent, family members, and healthcare providers. This ensures that everyone involved in your care is aware of your wishes and can act accordingly.

  10. Can I use Five Wishes alongside other legal documents?

    Yes, you can use Five Wishes in conjunction with other legal documents like a durable power of attorney or a traditional living will. If you decide to use Five Wishes instead of an existing document, make sure to revoke the old document properly to avoid any confusion.

Documents used along the form

When preparing for future health care decisions, the Five Wishes document is an important tool. However, it is often accompanied by other forms and documents that can further clarify your wishes and ensure they are honored. Below is a list of ten commonly used forms and documents that complement the Five Wishes document.

  • Advance Directive: This is a general term for legal documents that outline your preferences for medical treatment in case you become unable to communicate your wishes. It typically includes a living will and a durable power of attorney for health care.
  • Durable Power of Attorney for Health Care: This document allows you to appoint someone to make health care decisions on your behalf if you are unable to do so. It is a key component of your advance directive.
  • Living Will: This specific type of advance directive outlines your preferences regarding life-sustaining treatment and other medical interventions. It focuses on the types of medical care you do or do not wish to receive.
  • Articles of Incorporation: This legal document is essential for establishing a corporation in California, outlining key details such as the company's name and purpose. For more information, visit mypdfform.com/blank-california-articles-of-incorporation/.
  • Do Not Resuscitate (DNR) Order: This medical order indicates that you do not want to receive CPR or other life-saving measures if your heart stops or you stop breathing. It must be signed by a physician to be valid.
  • POLST (Physician Orders for Life-Sustaining Treatment): This is a medical order that outlines your preferences for treatment in emergency situations. It is designed for individuals with serious illnesses and must be signed by a healthcare provider.
  • Health Care Proxy Form: Similar to a durable power of attorney, this document designates someone to make health care decisions for you if you are incapacitated. It often includes specific instructions regarding your care.
  • Organ Donation Registration: This form allows you to express your wishes regarding organ and tissue donation after your death. It can be included as part of your advance directive or completed separately.
  • Funeral Planning Document: This document outlines your wishes for your funeral and burial arrangements. It can help relieve your loved ones from making difficult decisions during a challenging time.
  • Family Caregiver Agreement: This informal document outlines the roles and responsibilities of family members or friends who will be involved in your care. It can help clarify expectations and reduce conflict.
  • Medical History Form: This form provides a comprehensive overview of your medical history, medications, allergies, and other relevant health information. It can be helpful for your health care agent and providers.

These documents work together to ensure that your health care preferences are clearly communicated and respected. It is essential to discuss these forms with your loved ones and health care providers to ensure everyone understands your wishes. Taking the time to prepare these documents can provide peace of mind for you and your family.

Document Sample

FIVE

WISH S®

M Y W I S H F O R :

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

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

How Comfortable3 I Want to Be

How I Want People4 to Treat Me

What I Want My Loved5 Ones to Know

print your name

birthdate

Five Wishes

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

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

What Is Five Wishes?

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

lets you say exactly how you wish to be

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

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

sentences.

How Five Wishes Can Help You And Your Family

It lets

you talk with your family,

 

 

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frie

 

 

 

 

 

 

 

 

 

without knowing your wishes.

 

 

nds and doctor about how you

 

 

wantt

 

 

 

 

 

 

 

 

 

 

to be treated if you become

• You can know what your mom, dad,

 

 

seriou

 

 

 

 

 

 

 

 

 

sly ill.

 

 

 

 

spouse, or friend wants. You can be

 

Your family membe

rs will not have to

 

there for them when they need you

 

 

 

 

 

t. It protects them

most. You will understand what they

 

 

guess what you wan

 

 

 

ously ill, because

really want.

 

 

if you become seri

How Five Wishes Began

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

2Five Wishes and the response to it has been

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

Who Should Use Five Wishes

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

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

Five Wishes States

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

Alaska

Illinois

Montana

 

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Arizona

Iowa

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Arkansas

Kentucky

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Tennessee

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Vermont

 

 

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Maine

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Virginia

 

 

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Maryland

 

 

 

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Washington

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Delaware

Massachusetts

 

 

 

 

 

 

 

 

 

West Virginia

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Florida

Michigan

 

 

 

 

 

 

 

Wisconsin

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Georgia

Minnesota

Oklahoma

 

 

 

Wyoming

Hawaii

Mississippi

 

 

 

 

 

 

 

 

 

 

 

 

Pennsylvania

 

 

 

 

 

Idaho

Missouri

 

 

 

 

 

 

 

 

Rhode Island

 

 

 

 

 

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

How Do I Change To Five Wishes?

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

D

estroy all copies of your old living will

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or durable power of attorney for health

 

members, and doctor that you have

 

care. Or you can write “revoked” in large

 

filled out a new Five Wishes.

 

letters across the copy you have. Tell

 

Make sure they know about your

 

your lawyer if he or she helped prepare

 

new wishes.

 

those old forms for you. AND

 

 

3

WISH 1

The Person I Want To Make Health Care Decisions For Me

When I Can’t Make Them For Myself.

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

 

 

 

• My attending or treating doctor finds I am no

I decisions, this form names the person I choose to

 

 

 

 

longer able to make health ca

 

es, AND

 

 

 

 

re choic

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

make these choices for me. This person will be my

 

 

 

• Another health care profe

ssional agrees

t

hat

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

 

 

 

 

this is true.

 

 

 

 

 

 

 

 

 

 

MPLE

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

 

 

If my state has a different

 

w

ay of finding that I am not

 

This person will make my health care choices if both

 

 

able to make health c

 

are choices, then my state’s way

 

of these things happen:

 

 

 

should be followe

d.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Person I Choose As My Health Care Agent Is:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Choice Name

 

 

Ph

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

one

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

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

Second Choice Name

 

 

 

 

 

e

 

Third Choice Nam

 

 

 

 

 

 

 

 

Address

 

A

 

 

 

 

 

 

ddress

 

 

 

 

 

 

 

 

 

 

 

 

City/State/Zip

 

 

City/State/Zip

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

 

Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Picking The R

 

Your Health Care Agent

 

ight Person To Be

 

 

 

 

 

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can make difficult

Agent should be at least 18 years or older (in

cares about you, and who

 

 

 

 

 

 

 

ily member may

&RORUDGR\HDUVRUROGHUDQGVKRXOGnot be:

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not be the best choice because they are too

 

 

Your health care provider, including the

 

 

 

 

 

 

 

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owner or operator of a health or residential

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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or community care facility serving you.

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ho is able to stand up for you so that your

 

 

 

 

 

 

 

 

 

 

 

 

wishes are followed. Also, choose someone who

 

 

An employee or spouse of an employee of

is likely to be nearby so that they can help when

 

 

 

 

your health care provider.

you need them. Whether you choose a spouse,

 

 

 

 

 

 

 

 

 

 

 

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Agent, make sure you talk about these wishes

 

 

 

 

more people unless he or she is your

and be sure that this person agrees to respect

 

 

 

 

spouse or close relative.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

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

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

Make choices for me about my medical care

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or services, like tests, medicine, or surgery.

 

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

 

This care or service could be to find out what my

 

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

 

sign it for me.

 

include care to keep me alive. If the treatment or

Move me to another

 

 

 

 

 

FDUHKDVDOUHDG\VWDUWHGP\+HDOWK&DUHAgent

state to get the care I need

 

 

 

or to carry out m

y wishes.

 

can keep it going or have it stopped.

 

 

 

 

 

 

 

 

 

Interpret any instructions I have given in

this form or given in other discussions, according

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‡ &RQVHQWWRDGPLVVLRQWRDQDVVLVWHGOLYLQJIDFLOLW\ hospital, hospice, or nursing home for me. My +HDOWK&DUH$JHQWFDQKLUHDQ\NLQGRIKHDOWK care worker I may need to help me or take care of me. My Agent may also fire a health care worker, if needed.

Make the decision to request, take away or not

JLYHPHGLFDOWUHDWPHQWVLQFOXGLQJDUWLILFLDOO\ provided food and water, andd any other treatments to keepp me alive.

Authorize or refuse to authorize any medication or procedure needed to help with pain.

Take any legal action needed to carry out my wishes.

Donate useable organs or tissues of mine as allowed by law.

• Apply for Medicare, Medicaid, or other programs RULQVXUDQFHEHQHILWVIRUPH0\+HDOWK&DUH Agent can see my personal files, like bank records, to find out what is needed to fill out these forms.

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______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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

Destroy all copies of this part of the

• Write the word “Revoked” in large

 

Five Wishes form. OR

letters across the name of each agent

• Tell someone, such as my doctor or

whose authority I want to cancel.

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family, that I want to cancel or change

 

 

 

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5

WISH 2

My Wish For The Kind Of Medical Treatment

I Want Or Don’t Want.

I b elieve that my life is precious and I deserve to be treated with dignity. When the timee comes that

I am very sick and am not able to speak for myself, I want the following wishes, and any other directions I have given to my Health Care Agent, to be respected and followed.

What You Should Keep In Mind As My Caregiver

I do not want to be in pain. I want my doctor to give me enough medicine to relieve my pain, even if that means that I will be drowsy or sleep more than I would otherwise.

I do nott want anything done or omitted by my doctors or nurses with the intention of taking my life.

I want to be offered food and fluids by mouth, and kept clean and warm.

What “Life-Support Treatment” Means To Me

/LIHVXSSRUWWUHDWPHQWPHDQVDQ\PHGLFDOSURFH dure, device or medication to keep me alive.

/LIHVXSSRUWWUHDWPHQWLQFOXGHVPHGLFDO devices put in me to help me breathe; food and ZDWHUVXSSOLHGE\PHGLFDOGHYLFHWXEHIHHGLQJ FDUGLRSXOPRQDU\UHVXVFLWDWLRQ&35PDMRU surgery; blood transfusions; dialysis; antibiotics;

and anything else meant to keep me alive.

,I,ZLVKWROLPLWWKHPHDQLQJRIOLIHVXSSRUW treatment because of my religious or personal beliefs, I write this limitation in the space below. I do this to make very clear what I want and under what conditions.

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

In Case Of An Emergency

Iff you have a medical emergency and ambulance personnel arrive, they may look to see if you have a Do Not Resuscitate form or bracelet. Many states require a person to have a Do Not Resuscitate form filled out and

signed by a doctor. This form lets ambulance SHUVRQQHONQRZWKDW\RXGRQ·WZDQWWKHPWRXVH OLIHVXSSRUWWUHDWPHQWZKHQ\RXDUHG\LQJ3OHDVH check with your doctor to see if you need to have a Do Not Resuscitate form filled out.

6

Here is the kind of medical treatment that I want or don’t want in the four situations listed below. I want my Health Care Agent, my family, my doctors and other health care providers, my friends and all others to know these directions.

Close to death:

If my doctor and another health care professional both decide that I am likely to die within a short period of WLPHDQGOLIHVXSSRUWWUHDWPHQWZRXOGRQO\GHOD\WKH PRPHQWRIP\GHDWK&KRRVHoneRIWKHIROORZLQJ

,ZDQWWRKDYHOLIHVXSSRUWWUHDWPHQW

, GRQRWZDQWOLIHVXSSRUWWUHDWPHQW,ILWKDV been started, I want it stopped.

,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

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________

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

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

WKHPMR\DQGQRWVRUURZ

After my death, I would like my body to

EHFLUFOHRQHEXULHGRUFUHPDWHG

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

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

9

Signing The Five Wishes Form

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

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

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

Signature:

 

 

___

Address:

 

 

 

 

 

 

Phone:

Date:

 

 

__

Witness Statement (2 witnesses needed):

,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

#1

 

 

 

 

 

 

 

 

 

 

Printed Name of Witn

 

 

 

 

 

Printed Name of Witness

ess

 

 

 

 

 

 

 

 

 

 

Address

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone

Phone

 

 

NotarizationOnly required for residents of Missouri, North Carolina, South Carolina and West Virginia

If you live in Missouri, only your signature should be notarized.

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10

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