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Living Will Sample - Five Wishes Form

Updated on January 1, 2012

As a Nurse working in Hospice Care, I was fortunate to be introduced to Five Wishes. Five Wishes National version of it's Living Will and Advance Directive was introduced in 1998. Let me begin with what the Five Wishes are and then I will go further into detail of all.

The Five Wishes

  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. How Comfortable I Want to Be
  4. How I Want People to Treat Me
  5. What I Want My Loved Ones to Know

I'll go into detail of each wish, but first, I'd like to make you aware of where the Five Wishes is available.

Five Wishes is a Living Will that is easy to complete and a legal, recognizable Will in America. Five Wishes currently meets the legal requirements for an advance directive in 42 states and the District of Columbia. In the remaining 8 states, a statutory form is required, and must be attached the State Document if Five Wishes is used. You can access this from your State Website or Doctor.

Wish One

The person I want making Healthcare choices for me when I can't make them for myself.

The person you appoint this position to should be one who you trust. They are being asked to carry out your wants and desires when you cannot. They should be very familiar with your choices of medical care, emotional care and spiritual care. Make sure this person gets a copy of your Living Will once you have completed it.

Wish Two

The kind of medical care I want and don't want.

This part of the Five Wishes is crucial. You want to make it clear what you want and what you don't. If you do not want to be resuscitated if your heart stops (DNR), this is the place. If you want a feeding tube although unconscious with little chance of survival, write it down.

Wish two is vital to the care you want and don't. Don't leave even the smallest detail out.

Unfortunately, we cannot predict the future. With that said, you don't know if a car accident has left you in a vegetative state without chance of survival. Think of how you would want to be treated medically in every situation possible and make it known what you want to be upheld.

Wish Three

My wish of how comfortable I want to be

This wish is designed for those who are in terminal state and deserve to be treated and die with the dignity they deserve. You would think that clipping nails or brushing your hair would be automatic in healthcare, but as a Nurse, I can tell you that it is unfortunate but realistically does not happen like it should.

Wish three is the place in-which you state that you would like your feet to be lotioned, your hair to be brushed, soft music, Jeopardy on TV nightly, ect. It's the way you want Healthcare providers or family to treat you daily. This is NOT being selfish. I had a lot of clients tell me that they felt selfish asking for people to do these things for them. After understanding that they would no longer have the ability to do it anymore for themselves, the picture became clearer. Ask for the things you do for yourself now that make you feel comfortable.   

Wish Four

How I want people to treat me

How do you wish to have people talk to you when you cannot respond? Sad, happy, in despair? If you would like to have prayers at bedside, visitors from your choice of religious congregation or your rosary in hand, Wish four is where you need to organize that. Wish three could also have some of this information.   

Wish Five

What I want my family and loved ones to know

For me, this was the hardest section. I have a lot I want my family to know if I become unable to speak or show them my feelings any longer. But it is important for them to know.

If you know where you would like to be buried, what Funeral Home to be contacted or any arrangements that your family needs to know,make it known here.

None of us want to think of ourselves not being a part of this life any longer, but it is something we must think about. Protect yourself by making a Living Will. If not Five Wishes, there are other kits and forms through your State that can be obtained. Whatever you decide, make sure to give a copy to your Doctor, your Proxy or appointed decision maker and keep a copy in your records. Living Wills not only protect your wishes but makes the decisions of your loved ones much easier as they deal in this difficult time.


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