5 Wishes Document PDF Form

Detailed Instructions for Filling Out 5 Wishes Document

The Five Wishes document is a powerful tool for anyone over the age of 18 to communicate their desires about various aspects of their care if they become unable to make decisions for themselves due to serious illness. This simple yet comprehensive form covers personal, emotional, spiritual, and medical preferences, making it easier for families, friends, and healthcare providers to honor an individual's wishes. The process of filling out the Five Wishes form ensures that your voice is heard at a time when you may not be able to speak for yourself, providing peace of mind for you and your loved ones. Here are the steps to complete the form:

1. Print your full name and birthdate at the top of the Five Wishes document to identify yourself as the person creating this living will.
2. To appoint your Health Care Agent, start with Wish 1:
   • Write the name, phone number, and address of your first choice for your Health Care Agent.
   • Fill in the details for a second and third choice for your Health Care Agent in case your first choice is unable or unwilling to take on this responsibility.
3. Consider the qualities important in a Health Care Agent, such as understanding your wishes, making difficult decisions, and being emotionally and geographically available. Discuss your wishes with the person(s) you choose to ensure they are willing and able to act on your behalf.
4. Decide on the powers and limitations you wish to grant your Health Care Agent under Wish 1 and mark the document accordingly. This may involve crossing out any powers you do not wish to grant. Your agent can make decisions about medical care, interpret your wishes, hire or fire health care workers, make decisions about life support and pain management, take legal actions, donate organs, and apply for benefits on your behalf.
5. If you wish to add any specific instructions or limitations for your Health Care Agent not covered by the standard choices, write these in the provided space. This could include specific treatments you do or do not want or particular care preferences.
6. In case you change your mind about having a Health Care Agent, understand that you can revoke this decision at any time by destroying the document, marking it as "Revoked," or informing your doctor or family of the change.
7. Sign and date the document to make your wishes official. Note that depending on your state's requirements, the Five Wishes document may also need to be witnessed or notarized to become legally binding.

Once you've completed these steps, keep your Five Wishes document in a safe but accessible place, and inform your family, Health Care Agent, and doctor where it is stored. Remember, this document reflects your wishes at a particular time. You can review and update it as your circumstances or preferences change, ensuring it always mirrors your current wishes.

1. What is the Five Wishes document?

   The Five Wishes document is a comprehensive living will that addresses not only medical but also personal, emotional, and spiritual needs at the end of life. It allows an individual to outline how they wish to be treated if they become seriously ill and are unable to make their own health care decisions. This document helps in choosing a health care agent, specifying the kind of medical treatment desired, determining comfort levels, addressing how the individual wants to be treated by others, and expressing what they want their loved ones to know.

2. Who should use Five Wishes?

   Anyone over the age of 18 can benefit from completing the Five Wishes document, including but not limited to married individuals, single adults, parents, adult children, and friends. It has been widely adopted due to its comprehensive approach, making it a useful tool for lawyers, doctors, hospitals, hospices, faith communities, employers, and retiree groups to distribute. Over 19 million people have already used it to articulate their end-of-life preferences.

3. Is Five Wishes legally valid in all states?

   Five Wishes meets the legal requirements for a living will in 42 states and the District of Columbia. If you live in one of these states, your document will be recognized and can bring peace of mind. However, if your state is not among the 42 listed, while some doctors may be hesitant to honor it, Five Wishes can still serve as a powerful guide for your loved ones and health care providers by clearly stating your health care and personal wishes. Many individuals in unlisted states fill it out alongside their state's legal forms to ensure their full wishes are expressed and considered.

4. How can I change to Five Wishes from another advance directive?

   If you have previously completed a living will or durable power of attorney for health care but wish to switch to Five Wishes, you should fill out and sign the Five Wishes document as instructed to make it your current advance directive. It is important to destroy all copies of your previous directive or write “revoked” across them clearly. Inform your health care agent, family members, and doctor about this change and make sure they have access to the new Five Wishes document. This ensures that your most current wishes regarding health care decisions are known and can be followed.

When it comes to completing the Five Wishes document, some people overlook the importance of carefully selecting their Health Care Agent. Not knowing that this decision should be grounded in trust and practicality, they might choose someone who either doesn't fully understand their values or is unable to advocate firmly on their behalf. It's crucial that the appointed individual is not only willing but also capable of making decisions that align with the person's wishes, especially under stressful circumstances.

Another common mistake is not discussing their wishes in detail with the chosen Health Care Agent. Communication is key for ensuring that the agent is fully prepared to make decisions that reflect what the person would have wanted. Without these discussions, agents are left to make critical decisions with incomplete information, potentially leading to choices that the person might not have agreed with.

Many people also fail to regularly review and update their Five Wishes document. Life changes, such as shifts in personal relationships or health status, can affect one's decisions about care. By not revisiting the document, important updates might be overlooked, leading to a plan that no longer accurately reflects the person's current wishes.

Similarly, there is often a mistake in not understanding the legal requirements that validate the document. The laws vary by state, and failing to comply with specific state requirements can render the document ineffective. This misstep can complicate or delay the implementation of the person's wishes during critical times.

Some individuals make the mistake of filling out the document but not sharing it with important people, such as family members or their primary healthcare provider. Keeping the document secret defeats its purpose, as the people who need to be aware of one's wishes won't have access to the document when it's needed most.

Lastly, a significant error is not fully considering or articulating the type of medical treatment desired, especially under various circumstances. The document allows for detailed preferences regarding treatments and interventions. By not being clear or detailed about these preferences, individuals risk receiving care that goes against their values and wishes.

When preparing for how you want to be treated in serious medical situations, using the Five Wishes Document is a powerful step in making your desires known. However, integrating other healthcare directives and documents can strengthen your plan, ensuring broader aspects of your well-being and wishes are honored. Below are supplementary forms and documents that frequently accompany the Five Wishes Document.

• Living Will - A legal document that records your wishes regarding life-sustaining treatments if you are terminally ill or in a persistent vegetative state and can no longer communicate your decisions.
• Durable Power of Attorney for Health Care - This authorizes someone you trust to make health care decisions on your behalf if you're incapacitated. Unlike the Five Wishes Document, which includes personal, emotional, and spiritual desires, this form focuses solely on healthcare decisions.
• Do Not Resuscitate (DNR) Order - A medical order signed by a doctor, specifying that in the case of a cardiac or respiratory arrest, resuscitation efforts should not be attempted. This document speaks to more immediate medical situations.
• Organ and Tissue Donation Registration Form - While the Five Wishes Document can include your wish to donate your organs, an official registration form makes your consent to donate organs and tissues clear to healthcare professionals and family members.
• Personal Property Memorandum - Although not directly related to healthcare decisions, this document allows you to allocate tangible personal property not otherwise specified in your will. It can ease the burden on family members by directing personal items to specific loved ones, reflecting your wishes for the distribution of sentimental items.

Incorporating these documents with your Five Wishes Document can provide a comprehensive approach to planning for your future health care and personal wishes. Each plays a unique role in ensuring that all aspects of your care and estate are handled according to your desires, offering peace of mind to both you and your loved ones. Embracing a clear and complete planning process puts the power in your hands, even when you might not be able to speak for yourself.

• Living Will: Much like the Five Wishes document, a living will provides instructions on how one wishes to be treated in terms of medical care when they are unable to make decisions for themselves. It specifies the types of medical treatment the individual wants or doesn't want under certain conditions, especially concerning life-sustaining procedures.

• Durable Power of Attorney for Health Care (Health Care Proxy): This legal document is similar to Wish 1 in the Five Wishes, where an individual nominates someone else to make healthcare decisions on their behalf if they become incapacitated. The named person has the authority to speak with doctors and make critical medical decisions when the individual is unable to do so themselves.

• Do Not Resuscitate (DNR) Order: A DNR order is a medical order that tells healthcare providers not to perform CPR if a patient's breathing stops or if the patient's heart stops beating. The Five Wishes document addresses similar concerns about the extent of medical interventions an individual wishes to receive, as outlined in Wish 2, where it discusses the kinds of medical treatment desired.

• Medical Orders for Life-Sustaining Treatment (MOLST or POLST): Similar to the Five Wishes, these forms provide instructions for healthcare providers regarding the use of life-sustaining treatments, including resuscitation, mechanical ventilation, and artificial nutrition and hydration. Wish 2 of the Five Wishes document allows an individual to express their wishes regarding such treatments.

• Emergency Medical Services (EMS) DNR Order: This pre-hospital medical directive prevents emergency medical personnel from administering resuscitative services in the event of cardiac or respiratory arrest. While the Five Wishes document primarily aims at providing guidance for longer-term care, it similarly allows individuals to state their preferences regarding emergency treatments in critical situations.

• HIPAA Release Form: The Health Insurance Portability and Accountability Act (HIPAA) release form allows healthcare providers to share an individual's medical information with designated people. The Five Wishes document complements this by naming a healthcare proxy who would need access to one's medical information to make informed decisions on their behalf, aligning with the intention behind HIPAA releases.

When completing the Five Wishes document, it's crucial to approach it with thoughtfulness and care. This document significantly influences how you'll be treated in serious medical situations when you can't make decisions yourself. Below are essential dos and don'ts to guide you in this important process.

Dos:

1. Read the entire document thoroughly before you start filling it out to ensure you understand all parts.
2. Choose a Health Care Agent who knows you well, cares about your well-being, and can handle the responsibility.
3. Discuss your wishes with the person you intend to name as your Health Care Agent to ensure they are willing and comfortable with the role.
4. Be specific about your medical treatment preferences, comfort measures, how you want to be treated, and what you want your loved ones to know.
5. Consult with a healthcare professional if you have questions about the medical treatment options presented.
6. Sign the document in the presence of the required witnesses or a notary public, according to your state's laws.
7. Tell your family, friends, and especially your healthcare provider about your Five Wishes document.
8. Keep the original document in a safe but accessible place, and provide copies to your Health Care Agent, doctor, and family.
9. Review and update your Five Wishes document periodically, especially after any major life changes.
10. If you wish to revoke or amend the document, follow the proper procedures to ensure your previous wishes are not followed.

Don'ts:

1. Don't choose a Health Care Agent without discussing it with them first.
2. Don't leave any sections incomplete; ensure your wishes are fully documented.
3. Don't use vague language; be clear and precise in your instructions and wishes.
4. Don't forget to consider all aspects of care, including emotional and spiritual needs, in addition to medical treatment.
5. Don't overlook the importance of legal requirements; make sure your document complies with your state's laws.
6. Don't keep your Five Wishes document a secret from those who need to know, especially your Health Care Agent and family.
7. Don't fail to sign and date the document according to legal requirements, rendering it invalid.
8. Don't assume your job is done once the document is completed; communicate and clarify your wishes as needed.
9. Don't hesitate to make changes if your preferences or circumstances change.
10. Don't ignore the need to make a new document if you revoke the old one; ensure your current wishes are documented and valid.

Properly completing and maintaining your Five Wishes document helps ensure that your healthcare preferences are respected and followed, providing peace of mind for you and your loved ones.

There are several common misconceptions about the Five Wishes document that could affect its intended use and effectiveness. Understanding these misconceptions can help individuals make more informed decisions when considering this form of living will.

• It replaces the need for a durable power of attorney for health care. This misconception is widespread. While Five Wishes does allow you to choose someone to make health care decisions on your behalf, it complements rather than replaces the durable power of attorney for health care in states where both are recognized.
• The document is legally valid in all US states. Although Five Wishes meets the legal requirements in 42 states and the District of Columbia, it may not be recognized as a substitute for statutorily prescribed forms in the remaining states. People in these states should consult local laws and possibly integrate Five Wishes with state-specific forms.
• Five Wishes is only for the elderly or terminally ill. This document is valuable for any adult, regardless of their current health status. It encourages discussions about care preferences in situations where one cannot speak for themselves due to severe illness or injury, applicable to adults of all ages.
• Completing the form guarantees my wishes will be followed. Although Five Wishes clearly communicates preferences regarding health care and personal matters, it cannot guarantee that all wishes will be followed to the letter. Difficulties may arise due to medical, legal, or ethical constraints. Effective communication with health care agents and providers is essential.
• Only a lawyer can complete the form correctly. Five Wishes is designed to be user-friendly, allowing individuals to complete it without legal assistance. It invites personal reflection and discussion with loved ones and medical providers, although consulting a lawyer can provide clarity on legal matters.
• The document is too complicated and time-consuming to fill out. Contrary to this belief, Five Wishes is written in plain language, making it accessible and straightforward for most people to complete. It guides the user through various decisions, from medical care to personal and spiritual wishes, without requiring extensive legal or medical knowledge.

Correcting these misconceptions can help individuals approach Five Wishes with a clearer understanding of its purpose and scope. This, in turn, aids in better preparing for future health care decisions and in communicating one's desires to family, friends, and medical providers.

The Five Wishes document is a comprehensive tool designed to help individuals articulate their preferences regarding medical treatment, comfort, how they wish to be treated by others, and what they want their loved ones to know if they are unable to make these decisions themselves due to serious illness. Here are four key takeaways about filling out and using the Five Wishes Document form:

• Universal Applicability: The document is intended for anyone over the age of 18, regardless of their current health status. This wide applicability ensures that individuals have the opportunity to express their wishes regarding healthcare and personal matters before they are unable to do so.
• Legally Recognized: Once completed and properly signed, the Five Wishes document is legally valid in the District of Columbia and 42 states. This legal recognition highlights the importance of ensuring the document is filled out correctly to act as a reliable source of one’s wishes in critical times.
• Comprehensive Coverage: Five Wishes covers personal, emotional, spiritual, and medical preferences, which are often overlooked in traditional living wills. This holistic approach ensures that a broad range of considerations is addressed, going beyond mere medical treatments to include personal dignity and emotional well-being.
• Facilitates Communication: By encouraging discussions with family, friends, and healthcare providers about end-of-life wishes, the Five Wishes document helps reduce the burden on loved ones to make difficult decisions without guidance. Knowing and understanding someone's preferences can be a significant comfort during challenging times.

It's critical to communicate with the person selected as your Health Care Agent to make sure they understand and are willing to respect your wishes. Changing existing living wills or health care power of attorney documents to the Five Wishes should be done by filling out a new Five Wishes document and informing family members and healthcare providers of the change. This ensures that the most current document reflects your desires and is recognized by those involved in your care.