Five Wishes Document

Reprinted with permission

PART B — Wishes 3, 4, and 5

Page Four of Five Pages — Return to Page One

I want to be treated with dignity near the end of my life as Part A of Five Wishes is followed. To be treated with dignity means that I would like people to do the things written in Part B when it [sic] 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 the things, or are not required by law to do the things written in Part B.

I do not expect my wishes in Part B to place new or added legal duties on my doctors or other health care providers. I also do not expect these wishes in Part B to excuse my doctor or other health care providers from giving me the proper care asked for by law.

Part B -- 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 give me enough medicine to relieve my pain, even if that means that 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 caregivers to do whatever they can to help me.

I wish to have a cool most cloth put on 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 wish 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.

I wish to have religious readings and well loved poems read aloud when I am near death.

Part B -- 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 to when possible, even if I don't seem to 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 church or synagogue 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.

Part B -- 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 members and loved ones 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 members and friends know that I forgive them for what they may have done to me in my life.

I wish for my family members and loved ones to know that because of the faith I have, I do not fear death itself. I think it is not the end, but a new beginning for me.

I wish for all 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 had a terminal illness. I want them to remember me in this way after my death.

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 live 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 them joy and not sorrow.

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

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

The following person knows my funeral wishes:

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

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):

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

Add other wishes here (such as your wishes about donating any or all parts of your body when you die):

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

Five Wishes is CONCLUDED on Page Five

© Copyright Commission on Aging with Dignity