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SAMPLE - Five Wishes

112345MY WISH FOR:The Person I Want to Make care Decisions for Me When I Can tThe Kind of Medical Treatment I Want or Don t WantHow Comfortable I Want to BeHow I Want People to Treat MeWhat I Want My Loved Ones to KnowPrint Your NameBirthdateSAMPLE2 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 Wishes is the first living will (also called an advance directive) that talks about your personal, emotional, and spiritual needs as well as your medical Wishes .

Health Care Agent (or other term that may be used in my state, such as proxy, representative, or surrogate). This person will make my health care choices if both of these things happen: • My attending or treating doctor finds I am no longer able to make health care choices, AND • Another health care professional agrees that this is true.

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