Five Wishes Document

Reprinted with permission

Part A — Wish 2: My Wish For the Kind of Medical Treatment I Want or Don't Want

Page Three of Five Pages — Return to Page One

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 instructions I have given to my Health Care Agent, to be respected and followed.

The instructions that I am including in this section are to let my family, my doctors and other health care providers, my friends and all others know the kind of medical treatment that I want or don't want.

A. General Instructions

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 not 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.

B. Meaning of "Life-Support Treatment"

Life-support treatment means any medical procedure, device or medication to keep me alive. Life-support treatment includes: medical devices put in me to help me breathe; food and water supplied artificially by medical device (tube feeding); cardiopulmonary resuscitation (CPR); major surgery; blood transfusions; dialysis; and antibiotics.

If I wish to limit the meaning of life-support treatment, I write this limitation in the space below:

[ On the printed form there is space provided for you to write ]

C. If I am close to death:

If my doctor and another health care professional both decide that I am likely to die within a short period of time, and life-support treatment would only postpone the moment of my death (choose one of the following):

I want to have life-support treatment.

I want to have life-support treatment if my doctor believes it could help, but I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.

I do not want life-support treatment. If it has been started, I want it stopped.

D. If I am in a coma and I am not expected to 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 to wake up or recover, and I have brain damage, and life-support treatment would only postpone the moment of my death (choose one of the following):

I want to have life-support treatment.

I want to have life-support treatment if my doctor believes it could be helpful, but I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.

I do not want life-support treatment. If it has been started, I want it stopped.

E. If I have permanent and severe brain damage and I am not expected to recover:

If my doctor and another health care professional both decide that I have permanent and severe brain damage, (for example, I can open my eyes, I can not speak or understand) and I am not expected to recover, and life-support treatment would only postpone the moment of my death (choose one of the following):

I want to have life-support treatment.

I want to have life-support treatment if my doctor believes it could help, but I want my doctor to stop giving me life-support treatment if it is not helping my health condition or symptoms.

I do not want life-support treatment. If it has been started, I want it stopped.

F. If I am in another condition under which I do not wish to be kept alive:

If there is another condition under which I do not wish to have life-support treatment, I describe it below. In this condition, I believe that the costs and burdens of life-support treatment are too much and not worth the benefits to me. Therefore, in this condition, I do not want life-support treatment.

(Please write the condition or conditions in the space below, or leave the space blank if you have none):

[ On the printed form there is space provided for you to write ]

When you talk with your family, doctor, Heath Care Agent, and priest, minister or rabbi about what you have chosen, you may feel that the above instructions do not express all of your wishes, or your own religious beliefs.

(Please use the space below to make very clear what you want, and under what conditions.)

[ On the printed form there is space provided for you to write ]

Five Wishes is CONTINUED on Page Four

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