FIVE

WISHES
®

MY WISH FOR:

1
The Person I Want to Make Care Decisions for Me When I Can’t

2
The Kind of Medical Treatment I Want or Don’t Want

3 I Want to Be
How Comfortable

4 to Treat Me
How I Want People

5
What I Want My Loved 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 something very important—how you are
treated if you get seriously ill. It is an 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 of most states.

What Is Five Wishes?

Five Wishes is the first living will that talks to be treated if you get seriously ill. It was
about your personal, emotional and spiritual written with the help of The American Bar
needs as well as your medical wishes. It lets Association’s Commission on Law and
you choose the person you want to make Aging, and the nation’s leading experts in
health care decisions for you if you are not end-of-life care. It’s also easy to use. All you
able to make them for yourself. Five have to do is check a box, circle a direction,
Wishes lets you say exactly how you wish or write a few sentences.

How Five Wishes Can Help You And Your Family

• It lets you talk with your family, friends because they won’t have to make hard
and doctor about how you want to be choices without knowing your wishes.
treated if you become seriously ill. • You can know what your mom, dad,
• Your family members will not have spouse, or friend wants. You can be there
to guess what you want. It protects for them when they need you most. You
them if you become seriously ill, will understand what they really want.

How Five Wishes Began

For 12 years, Jim Towey worked closely the response to it has been overwhelming. It
with Mother Teresa, and, for one year, he has been featured on CNN and NBC's Today
lived in a hospice she ran in Washington, Show and in the pages of Time and Money
DC. Inspired by this first-hand experience, magazines. Newspapers have called Five
Mr. Towey sought a way for patients and Wishes the first “living will with a heart and
their families to plan ahead and to cope with soul.” Today, Five Wishes is available in 27
serious illness. The result is Five Wishes and languages.

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Who Should Use Five Wishes
Five Wishes is for anyone 18 or older — works so well, lawyers, doctors,
married, single, parents, adult children, and hospitals and hospices, faith
friends. More than 19 million people of all communities, employers, and retiree
ages have already used it. Because it groups are handing out this document.

Five Wishes States

If you live in the District of Columbia or one of the 42 states listed below, you can
use Five Wishes and have the peace of mind to know that it substantially meets your
state’s requirements under the law:
Alaska Illinois Montana South Carolina
Arizona Iowa Nebraska South Dakota
Arkansas Kentucky Nevada Tennessee
California Louisiana New Jersey Vermont
Colorado Maine New Mexico Virginia
Connecticut Maryland New York Washington
Delaware Massachusetts North Carolina West Virginia
Florida Michigan North Dakota Wisconsin
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 requirements in the statutes of your state. So some doctors in your state
may be reluctant to honor Five Wishes. However, many people from states not on
this list do complete Five Wishes along with their state’s legal form. They find
that Five Wishes helps them express 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:

• Destroy all copies of your old living • Tell your Health Care Agent,
will or durable power of attorney family members, and doctor that
for health care. Or you can write you have filled out a new Five
“revoked” in large letters across the Wishes. Make sure they know
copy you have. Tell your lawyer if about your new wishes.
he or she helped prepare those old
3
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.

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

care decisions, this form names the person I
choose to make these choices for me. This person
•

•
My attending or treating doctor finds I am no longer
able to make health care choices, AND
Another health care professional agrees that
will be my Health Care Agent (or other term that this is true.
may be used in my state, such as proxy, represent- If my state has a different way of finding that I am
ative, or surrogate). This person will make my not able to make health care choices, then my
health care choices if both of these things happen: state’s way should be followed.

The Person I Choose As My Health Care Agent Is:

First Choice Name Phone

Address City/State/Zip

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

Second Choice Name Third Choice Name

Address Address

City/State/Zip City/State/Zip

Phone Phone

Picking The Right Person To Be Your Health Care Agent

Choose someone who knows you very well, and follow your wishes. Your Health Care
cares about you, and who can make difficult Agent should be at least 18 years or older (in
decisions. A spouse or family member may not Colorado, 21 years or older) and should not be:
be the best choice because they are too • Your health care provider, including
emotionally involved. Sometimes they are the the owner or operator of a health or
best choice. You know best. Choose someone residential or community care facility
who is able to stand up for you so you’re your serving you.
wishes are followed. Also, choose someone who
is likely to be nearby so that they can help when • An employee or spouse of an employee
you need them. Whether you choose a spouse, of your health care provider.
family member, or friend as your Health Care • Serving as an agent or proxy for 10
Agent, make sure you talk about these wishes or more people unless he or she is
and be sure that this person agrees to respect your spouse or close relative.

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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 • See and approve release of my medical
care or services, like tests, medicine, or records and personal files. If I need to sign
surgery. This care or service could be to my name to get any of these files, my
find out what my health problem is, or Health Care Agent can sign it for me.
how to treat it. It can also include care to • Move me to another state to get the care I
keep me alive. If the treatment or care has need or to carry out my wishes.
already started, my Health Care Agent can • Authorize or refuse to authorize any
keep it going or have it stopped. medication or procedure needed to help
• Interpret any instructions I have given in with pain.
this form or given in other discussions, • Take any legal action needed to carry out my
according to my Health Care Agent's wishes.
understanding of my wishes and values. • Donate useable organs or tissues of mine as
• Consent to admission to an assisted living allowed by law.
facility, hospital, hospice, or nursing • Apply for Medicare, Medicaid, or other
home for me. My Health Care Agent can programs or insurance benefits for me. My
hire any kind of health care worker I may Health Care Agent can see my personal files,
need to help me or take care of me. My like bank records, to find out what is needed to
Agent may also fire a health care worker, fill out these forms.
if needed.
• Listed below are any changes, additions, or
limitations on my Health Care Agent’s powers.

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

• Destroy all copies of this part of • Write the word “Revoked” in large
the Five Wishes form. OR letters across the name of each
agent whose authority I want to
• Tell someone, such as my doctor or
cancel. Sign my name on that page.
family, that I want to cancel or
change my Health Care Agent. OR

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 WISH 2
My Wish For The Kind Of Medical
Treatment I Want Or Don’t Want.

I believe that my life is precious and I deserve to be treated with dignity. When the time 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 • I do not want anything done or omitted by
to give me enough medicine to relieve my my doctors or nurses with the intention of
pain, even if that means that I will be drowsy taking my life.
or sleep more than I would otherwise.
• I want to be offered food and fluids
by mouth, and kept clean and warm.

What “Life-Support Treatment” Means To Me

Life-support treatment means any medical antibiotics; and anything else meant to keep me
procedure, device or medication to keep me alive. alive. If I wish to limit the meaning of life-
Life-support treatment includes: medical devices support treatment because of my religious or
put in me to help me breathe; food and water personal beliefs, I write this limitation in the
supplied by medical device (tube feeding); space below. I do this to make very clear what
cardiopulmonary resuscitation (CPR); major I want and under what conditions.
surgery; blood transfusions; dialysis;

In Case Of An Emergency
If you have a medical emergency and lets ambulance personnel know that you don't
ambulance personnel arrive, they may look want them to use life-support treatment when
to see if you have a Do Not Resuscitate you are dying. Please check with your doctor
form or bracelet. Many states require a to see if you need to have a Do Not
person to have a Do Not Resuscitate form Resuscitate form filled out.
filled out and signed by a doctor. This form

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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: Permanent And Severe Brain Damage

If my doctor and another health care professional both And Not Expected To Recover:
decide that I am likely to die within a short period of If my doctor and another health care professional
time, and life-support treatment would only delay the both decide that I have permanent and severe brain
moment of my death (Choose one of the following): damage, (for example, I can open my eyes, but I can
❏ I want to have life-support treatment. not speak or understand) and I am not expected to
❏ I do not want life-support treatment. If it has get better, and life-support treatment would only
been started, I want it stopped. delay the moment of my death (Choose one of the
following):
❏ I want to have life-support treatment if my
❏ I want to have life-support treatment.
doctor believes it could help. But I want my
doctor to stop giving me life-support ❏ I do not want life-support treatment. If it has been
treatment if it is not helping my health started, I want it stopped.
condition or symptoms. ❏ I want to have life-support treatment if my
In A Coma And Not Expected To doctor believes it could help. But I want my
doctor to stop giving me life-support treatment
Wake Up Or Recover:
if it is not helping my health condition or
If my doctor and another health care professional both symptoms.
decide that I am in a coma from which I am which I
In Another Condition Under Which
am not expected to wake up or recover, and I have
brain damage and life-support treatment would only I Do Not Wish To Be Kept Alive:
delay the moment of my death (Choose one of the If there is another condition under which I do not
following): wish to have life-support treatment, I describe it
❏ I want to have life-support treatment. below. In this condition, I believe that the costs and
burdens of life-support treatment are too much and
❏ I do not want life-support treatment. If it has not worth the benefits to me. Therefore, in this
been started, I want it stopped. condition, I do not want life-support treatment. (For
❏ I want to have life-support treatment if my example, you may write "end-stage condition." That
doctor believes it could help. But I want my means that your health has gotten worse. You are not
doctor to stop giving me life-support able to take care of yourself in any way, mentally or
treatment if it is not helping my health physically. Life-support treatment will not help you
condition or symptoms. recover. Please leave the space blank if you have no
other condition to describe.)

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 T he 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 me the proper care asked for by law.

WISH 3
My Wish For How Comfortable I Want To Be.
(Please cross out anything that you don’t agree with.)
• I do not want to be in pain. I want my doctor to • I wish to be massaged with warm oils as
give me enough medicine to relieve my pain, often as I can be.
even if that means I will be drowsy or sleep • I wish to have my favorite music played
more than I would otherwise. when possible until my time of death.
• If I show signs of depression, nausea, shortness • I wish to have personal care like shaving,
of breath, or hallucinations, I want my care nail clipping, hair brushing, and teeth
givers to do whatever they can to help me. brushing, as long as they do not cause me
• I wish to have a cool moist cloth put on my pain or discomfort.
head if I have a fever. • I wish to have religious readings and
• I want my lips and mouth kept moist to well-loved poems read aloud when I am
stop dryness. near death.
• I wish to have warm baths often. I wish to be • I wish to know about options for hospice care
kept fresh and clean at all times.
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 • I wish to be cared for with kindness and
want someone to be with me when it seems cheerfulness, and not sadness.
that death may come at any time. • I wish to have pictures of my loved ones
• I wish to have my hand held and to be talked to in my room, near my bed.
when possible, even if I don’t seem to respond • If I am not able to control my bowel or
to the voice or touch of others. bladder functions, I wish for my clothes
• I wish to have others by my side praying for and bed linens to be kept clean, and for
me when possible. them to be changed as soon as they can be
if they have been soiled.
• I wish to have the members of my faith
• I want to die in my home, if that can be
community told that I am sick and asked to
done.
pray for me and visit me.

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 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 • I wish for my family and friends and
know that I love them. caregivers to respect my wishes even if
• I wish to be forgiven for the times I have they don't agree with them.
hurt my family, friends, and others. • I wish for my family and friends to
• I wish to have my family, friends and look at my dying as a time of personal
others know that I forgive them for when growth for everyone, including me.
they may have hurt me in my life. This will help me live a meaningful
• I wish for my family and friends to know life in my final days.
that I do not fear death itself. I think it is • I wish for my family and friends to get
not the end, but a new beginning for me. counseling if they have trouble with my
death. I want memories of my life to give
• I wish for all of my family members to make them joy and not sorrow.
peace with each other before my death, if • After my death, I would like my body to be
they can. (circle one): buried or cremated.
• I wish for my family and friends to think • My body or remains should be put in the
following location ___________________.
about what I was like before I became
• The following person knows my funeral
seriously ill. I want them to remember me in
wishes: ____________________________.
this way after my death.

If anyone asks how I want to be remembered, please say the following about me:

If there is to be a memorial service for me, I wish for this service to include the following (list music,
songs, readings or other specific requests that you have):

(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 separate sheet of paper if you need more space.)

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 Signing The Five Wishes Form
Please make sure you sign your Five Wishes form in the presence of the two witnesses.
I, , ask that my family, my doctors, and other health care providers,
my friends, and all others, follow my wishes as communicated by my Health Care Agent (if I have one and he
or she is available), or as otherwise expressed in this form. This form becomes valid when I am unable to make
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):

I, the witness, declare that the person who signed or acknowledged this form (hereafter “person”) is personally known to me,
that he/she signed or acknowledged this [Health Care Agent and/or Living Will form(s)] in my presence, and that he/she
appears to be of sound mind and under no duress, fraud, or undue influence.
I also declare that I am over 18 years of age and am NOT:
• The individual appointed as (agent/proxy/ • Financially responsible for the person’s health care,
surrogate/patient advocate/representative) • An employee of a life or health insurance provider for
by this document or his/her successor, the person,
• The person’s health care provider, including
owner or operator of a health, long-term • Related to the person by blood, marriage, or adoption,
care, or other residential or community care and,
facility serving the person, • To the best of my knowledge, a creditor of the person or
• An employee of the person’s health care entitled to any part of his/her estate under a will or
provider, 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 #1 Signature of Witness #2

Printed Name of Witness Printed Name of Witness

Address Address

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. • If you live in North Carolina, South Carolina or West Virginia,
you should have your signature, and the signatures of your
witnesses, notarized.

STATE OF COUNTY OF

On this day of , 20 , the said ,

, and , known to me (or satisfactorily proven) to be the person named in
the foregoing instrument and witnesses, respectively, personally appeared before me, a Notary Public, within and for the State and County aforesaid,
and acknowledged that they freely and voluntarily executed the same for the purposes stated therein.

My Commission Expires:
10 Notary Public
What To Do After You Complete Five Wishes

• Make sure you sign and witness the form • Talk to your doctor during your next office
just the way it says in the directions. Then visit. Give your doctor a copy of your Five
your Five Wishes will be legal and valid. Wishes. Make sure it is put in your medical
• Talk about your wishes with your health record. Be sure your doctor understands
your wishes and is willing to follow them.
care agent, family members and others
Ask him or her to tell other doctors who
who care about you. Give them copies of
treat you to honor them.
your completed Five Wishes.
• If you are admitted to a hospital or nursing
• Keep the original copy you signed in a home, take a copy of your Five Wishes with
special place in your home. Do NOT you. Ask that it be put in your medical record.
put it in a safe deposit box. Keep it
• I have given the following people copies of my
nearby so that someone can find it when completed Five Wishes:
you need it.
__________________________________
• Fill out the wallet card below. Carry it __________________________________
with you. That way people will know __________________________________
where you keep your Five Wishes.

Residents of WISCONSIN must attach the WISCONSIN notice statement to Five Wishes.
More information and the notice statement are available at www.agingwithdignity.org or 1-888-594-7437.

Residents of Institutions In CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, NEW YORK,

NORTH DAKOTA, SOUTH CAROLINA, and VERMONT Must Follow Special Witnessing Rules.
If you live in certain institutions (a nursing home, other licensed long term care facility, a home for the
mentally retarded or developmentally disabled, or a mental health institution) in one of the states listed above,
you may have to follow special “witnessing requirements” for your Five Wishes to be valid. For further
information, please contact a social worker or patient advocate at your institution.

Five Wishes is meant to help you plan for the future. It is not meant to give you legal advice. It does not try to
answer all questions about anything that could come up. Every person is different, and every situation is
different. Laws change from time to time. If you have a specific question or problem, talk to a medical or
legal professional for advice.
Five Wishes Wallet Card
✁
Important Notice to Medical Personnel: My primary care physician is:
I have a Five Wishes Advance Directive.
Name
Signature Address City/State/Zip
Please consult this document and/or my Health Care Phone
Agent in an emergency. My Agent is:
My document is located at:
Name
Address City/State/Zip
Phone

Cut Out Card, Fold and Laminate for Safekeeping

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 Here’s What People Are Saying About Five Wishes:
“It will be a year since my mother passed on. We knew what she wanted because she had the Five
Wishes living will. When it came down to the end, my brother and I had no questions on what we
needed to do. We had peace of mind.”
Cheryl K.
Longwood, Florida

“I must say I love your Five Wishes. It's clear, easy to understand, and doesn't dwell on the concrete issues
of medical care, but on the issues of real importance—human care. I used it for myself and my husband.”
Susan W.
Flagstaff, Arizona

“I don't want my children to have to make the decisions I am having to make for my mother.
I never knew that there were so many medical options to be considered. Thank you for such a
sensitive and caring form. I can simply fill it out and have it on file for my children.”
Diana W.
Hanover, Illinois
Diana

To Order:
Call (888) 5-WISHES to purchase more copies of Five Wishes,
the Five Wishes DVD, or Next Steps guides. Ask about the
“Family Package” that includes 10 Five Wishes, 2 Next Steps
guides and 1 DVD at a savings of more than 50%. For more
information visit Aging with Dignity’s website, or call for
details.

(888) 5-WISHES or (888) 594-7437

www.agingwithdignity.or

P.O. Box 1661

Tallahassee, Florida 32302-1661

Five Wishes is a trademark of Aging with Dignity. All rights reserved. The contents of this publication are copyrighted materials of Aging with Dignity. No part of this publication may be
reproduced, transmitted, or sold in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without written permission
from Aging with Dignity. While the contents of this document are copyrighted, you are permitted to photocopy them to provide a copy of your completed Five Wishes to your physician, care
provider, Health Care Agent, family members, or other loved ones. All other reproductions or uses of Five Wishes require permission from Aging with Dignity. Aging with Dignity wishes to thank
Oregon Health Decisions for contributing to the drafting of wish number two, and Kate Callahan, Charles Sabatino, and Tere Saenz for their help.

(06/11) © 2011 Aging with Dignity, PO Box 1661, Tallahassee, Florida 32302-1661 • www.agingwithdignity.org • (888) 594-7437