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Five Wishes Document

Part A — Wish 1: The Person I Want To Make Care Decisions For Me When I Can't, reprinted with permission

Page Two of Five Pages — Page One

If 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 will be my 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:

1. My attending or treating doctor finds that I am no longer able to make health care choices

2. Another health care professional agrees that this is true.

Picking the Right Person to be Your Health Care Agent

Choose someone who knows you very well and cares about you, and who can make difficult decisions. Sometimes a spouse or family member is not the best choice because they are too emotionally involved with you. Sometimes they are the best choice. You know best. Make sure you choose someone who is able to stand up for you so that your wishes are followed. Also, choose someone who is likely to be nearby so that they are ready to help you when you need them.

Whether you choose your spouse, family member or friend to be your Health Care Agent, make sure you talk about your wishes with this person and that he or she agrees to respect and follow them.

Your Health Care Agent should be at least 18 years or older (in Colorado, 21 years or older) and should not be:

your health care provider, including owner or operator of a health or residential or community care facility serving you.

an employee of your health care provider,

serving as an agent or proxy for 10 or more people unless he or she is your spouse or close relative.

The person I choose as my Health Care Agent is:

Name _____________ Phone Number _______ Address ___________ City/State/Zip _____

If this person

Is not able or willing to make these choices for me,

Is divorced or legally separated from me,

OR

This person has died,

Then these people are my next choices:

[ On the printed form there is space provided for you to write your second and third choice names ]

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 care or services, like tests, medicine, or surgery. This care or service could be to find out what my health problem is, or how to treat it. It can also include care to keep me alive. If the treatment or care has already started, my Health Care Agent can keep it going or have it stopped.

Interpret any instructions I have given in this form or given in other discussions, according to my Health Care Agent's understanding of my wishes and values.

Arrange for admission to a hospital, hospice, or nursing home for me. My Health Care Agent can hire any kind of health care worker I may need to help me or take care of me. My Agent may also fire a health care worker, if needed.

Make the decision to request, take away or not give medical treatments, including artificially-provided food and water, and any other treatments to keep me alive.

See and approve release of my medical records and personal files. If I need to sign my name to get any of these files, my Health Care Agent can sign for me.

Move me to another state, to carry out my wishes. My Health Care Agent can also move me to another state for other reasons.

Take any legal action needed to carry out my wishes.

Apply for Medicare, Medicaid, or other programs or insurance benefits for me. My Health Care Agent can see my personal files, like bank records, to find out what is needed to fill out these forms.

Listed below are any changes, additions, or other limitations on my Health Care Agent's powers:

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

If I change my mind about having a Health Care Agent, I will:

Destroy all copies of this Part of the Five Wishes form, OR

Write the word "Revoked" in large letters across the name of each agent whose authority I want to cancel and signing my name on that page, OR

Tell someone, such as my doctor or family, that I want to cancel or change my Health Care Agent.

Five Wishes is CONTINUED on Page Three

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