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5 Wishes Document PDF Form

The Five Wishes Document is a unique form that allows individuals to express their personal, emotional, and spiritual needs regarding medical care. It empowers you to choose someone to make health care decisions on your behalf when you are unable to do so. By completing this straightforward document, you can ensure that your wishes are known and respected during critical moments of your life.

Customize 5 Wishes Document

Table of Contents

In a world where uncertainties abound, the Five Wishes document serves as a vital tool for individuals seeking to express their healthcare preferences in a clear and compassionate manner. This form goes beyond the traditional living will by addressing not just medical decisions but also the emotional and spiritual aspects of care. It allows you to designate a trusted person to make healthcare decisions on your behalf when you are unable to do so. Additionally, it outlines your wishes regarding the type of medical treatment you desire or wish to avoid, ensuring that your comfort and dignity are prioritized. The document encourages open conversations with family members and healthcare providers, alleviating the burden of guesswork during critical moments. By articulating how you want to be treated and what you want your loved ones to know, Five Wishes empowers you to take control of your healthcare journey. Designed for anyone aged 18 and older, this accessible form has gained recognition and use across various communities, making it a valuable resource for millions. With its roots in the compassionate work of Jim Towey and Mother Teresa, Five Wishes has been embraced for its ability to bring heart and soul into the often daunting discussions surrounding end-of-life care.

Common mistakes

Inadequate Identification: Failing to clearly print your name and birthdate can lead to confusion. Ensure that this information is legible and accurate.
Choosing the Wrong Agent: Selecting a health care agent who may not be available or willing to advocate for your wishes can create complications. Choose someone who understands your values and can act in your best interest.
Neglecting to Discuss Wishes: Not having conversations with your chosen health care agent or family about your preferences can lead to misunderstandings. Open dialogue is crucial to ensure everyone is on the same page.
Not Revoking Previous Documents: If you have an existing living will or power of attorney, failing to revoke those can cause legal issues. Make sure to destroy old documents or clearly mark them as revoked.
Overlooking State Requirements: Ignoring specific state laws regarding living wills can invalidate your document. Always verify that the Five Wishes form meets your state’s legal requirements.

Example - 5 Wishes Document Form

FIVE

WISH S®

M Y W I S H F O R :

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

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

How Comfortable3 I Want to Be

How I Want People4 to Treat Me

What I Want My Loved5 Ones to Know

print your name

birthdate

Five Wishes

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

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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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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can make difficult

Agent should be at least 18 years or older (in

cares about you, and who

ily member may

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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
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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

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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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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

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________________________________________________________________________________________

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.

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•The individual appointed as (agent/proxy/

VXUURJDWHSDWLHQWDGYRFDWHUHSUHVHQWDWLYHE\ this document or his/her successor,

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

•$QHPSOR\HHRIWKHSHUVRQ·VKHDOWKFDUH provider,

•)LQDQFLDOO\UHVSRQVLEOHIRUWKHSHUVRQ·V health care,

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

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

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

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


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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Key takeaways

Filling out the Five Wishes Document form is an important step in ensuring that your health care preferences are respected. Here are some key takeaways to consider:

Understanding Five Wishes: This document serves as a living will, addressing not only medical decisions but also your personal, emotional, and spiritual needs.
Choosing a Health Care Agent: You can designate someone you trust to make health care decisions on your behalf if you are unable to do so. This person should be at least 18 years old and someone who knows your wishes well.
Clarity in Medical Treatment: The form allows you to specify the types of medical treatments you want or do not want, ensuring your preferences are clear to your health care providers.
Comfort and Care Preferences: You can express how comfortable you want to be and how you wish to be treated during serious illness, which can alleviate stress for both you and your family.
Communication with Family: Filling out this document fosters important conversations with your family about your wishes, preventing them from having to make difficult decisions without guidance.
Legal Validity: Once properly completed and signed, the Five Wishes document is valid in most states, making it a legally recognized tool for health care decision-making.
Revoking Previous Documents: If you have existing advance directives, you must destroy those copies or clearly indicate that they are revoked when you complete the Five Wishes form.
Access for Health Care Providers: Your designated Health Care Agent will have the authority to access your medical records and make decisions based on your documented wishes.
Widespread Acceptance: Many legal and health care professionals recommend Five Wishes, and it is recognized in 42 states, making it a widely accepted choice for advance care planning.

By understanding these key points, individuals can make informed choices about their health care and ensure that their wishes are honored, even when they cannot communicate them directly.

Form Attributes

Fact Name	Details
Purpose	The Five Wishes document allows individuals to express their medical, emotional, and spiritual preferences for end-of-life care.
Age Requirement	Anyone aged 18 or older can complete the Five Wishes document, making it accessible to a wide audience.
Legal Validity	Five Wishes is recognized as a valid advance directive in most states, provided it meets state-specific requirements.
State-Specific Laws	The document complies with laws in 42 states and the District of Columbia, including Alaska, Florida, and California.
Ease of Use	Five Wishes is designed to be simple to complete, requiring only checkboxes, circles, or brief written responses.
Communication Benefits	This document facilitates important conversations between individuals and their loved ones about healthcare preferences.

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Dos and Don'ts

When filling out the Five Wishes Document form, consider the following guidelines:

Do read the entire document carefully before starting.
Do choose someone you trust to make health care decisions for you.
Do communicate your wishes clearly to your chosen Health Care Agent.
Do ensure you sign and date the document as required.
Don't use vague language that may lead to confusion about your wishes.
Don't select a Health Care Agent who is not willing to respect your wishes.
Don't forget to inform family members about your completed document.
Don't leave any sections blank; complete all necessary fields.

5 Wishes Document PDF Form

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Dos and Don'ts