The Role of Five Wishes for Advance Care Planning

In the world of advance planning, Five Wishes is unique. It’s the only document designed to meet the legal requirements in all states, while also making advance care planning as easy as possible.

This is a powerful idea, as each state has its own regulations and differences in their requirements. State-developed documents can also seem complex and difficult to understand, which makes the whole process even more confusing.

This is where Five Wishes comes in. It’s a much easier document to work with, which can make it a lifesaver for many families. It’s especially powerful if you’re trying to help aging parents with their documents and makes everything much less stressful.

In this post, we’re digging into the specifics of Five Wishes and how it might help you.

What is Five Wishes?

Five Wishes is a legal document that functions as both a Healthcare Power of Attorney (PoA) and a Living Will throughout the United States. The document alone is legally valid in most states and just requires a little extra paperwork in the remaining states, so you can use it wherever you are. 

Five Wishes was designed to make advance care planning much more accessible.

It achieves this goal too, as it uses straightforward language and gives you instructions for every step of the way.

There’s another cool thing too – the extra wishes.

The last three sections of Five Wishes cover emotional, spiritual, and comfort needs, ones that aren’t found in any other advance planning documents. These allow you to address the things that matter most, giving loved ones a single place to find all your important information.

Now, these three sections aren’t legally binding in the way that the Living Will and PoA aspect is, but they’re still incredibly valuable.

Features of Five Wishes

Five Wishes lives up to its name and has five distinct sections. These can be seen below.

Wish 1: The Person I Want to Make Care Decisions for Me When I Can’t

Wish 1 is the PoA section of the form. It allows you to name an initial healthcare agent (also called your healthcare proxy) and a backup. The backup is just as important as your initial agent, as you can’t guarantee your desired proxy will be available when the time comes.

This section also allows you to choose what the proxy can do (and what you don’t want them to do). Some of the options include:

• Make choices about medical care or services
• Interpret instructions given in the form
• Consent to facility admission
• Apply for Medicare, Medicaid, etc.
• Authorize or refuse any medication

Wish 2: The Kind of Medical Treatment I Want or Don’t Want

Wish 2 is a Living Will. It starts with basic information about what you hope for and allows you to define precisely what life support treatment means for you.

Following this, there are three specific situations for which you can talk about the care you want. These are:

• Close to death
• Permanent and severe brain damage and not expected to recover
• In a coma and not expected to wake up or recover

For these, you can choose whether you want life support, don’t want life support, or only want it if the doctor believes it can help. You can also specify additional conditions in which you don’t want life support.

Wish 3: How Comfortable I Want to Be

Wish 3 focuses on comfort care. It includes items like:

• Personal care, including hair brushing, nail clipping, and the like
• Keeping your lips and mouth moist
• Warm baths
• Not wanting to be in pain

There are 10 statements for this wish, and you can simply cross out any you disagree with.

Wish 4: How I Want People to Treat Me

Wish 4 follows a similar approach to Wish 3, just with a focus on how you wish to be treated. Some aspects relate to faith, like whether you want people praying for you or the members of your faith community informed. Other aspects include the wish to die at home and to be treated with kindness.

Wish 5: What I Want My Loved Ones to Know

Finally, Wish 5 covers messages to pass on. This includes statements you can cross out and a few spaces where you can fill in specifics.

Signature Page

There is a single signature page for the whole document. Five Wishes requests that you have two witnesses and provides details about who these cannot be. There is also a section for notarization for the states where this is relevant. It’s a simple section to understand, regardless of your state.

Where is Five Wishes Valid?

Five Wishes has been designed to be legal in most states if you follow the instructions.

Things are a little more complex for anyone living in Kansas, New Hampshire, Ohio, or Texas. These states require an extra step, which can involve using another form in addition to the Five Wishes document. But, once you follow those steps, Five Wishes can generally be used as intended.

Benefits of Five Wishes

• Comprehensive, including spiritual, emotional, and comfort wishes that aren’t found elsewhere.
• User-friendly
• Prompts conversations
• Found in various formats and languages
• Easier language than normal

These benefits make Five Wishes an obvious choice for many people. After all, other advance directives can seem complicated and difficult to understand. End-of-life decisions are tough enough on their own. Who wants to deal with complex language and jargon as well?

Compatibility with Other Documents

Five Wishes is compatible with some advance planning documents but is designed to replace others. The following sections highlight the key interactions.

Also, crucially, if there are contradictions between any documents, doctors should go with the most recent information. That means the document with the most current date will be prioritized.

Five Wishes and Advance Directives

Five Wishes is sometimes described as being compatible with other advance directives, but that’s not accurate. Because Five Wishes is a Living Will and PoA, it replaces both of these documents.

This means you can’t fill out Five Wishes and have a state-designed Living Will or PoA to act as a backup. Also, if you complete a complex Living Will with your attorney, then complete Five Wishes because someone recommended it; Five Wishes becomes your only valid directive.

This is completely fine if you want to rely on Five Wishes.

If you want a different form to be legally valid, you’ll need to leave Five Wishes unsigned or skip it entirely.

Five Wishes and Medical Orders

Five Wishes is compatible with other types of documents, like Physician Orders for Life Sustaining Treatment (POLST) and DNR orders.

That’s because these documents generally translate the information from a Living Will into medical orders. In fact, people who are frail or have a significant illness should have medical orders in addition to their advance directives.

Five Wishes and Other PoAs

The PoA aspect of Five Wishes is mostly a healthcare PoA. As such, it should be compatible with other types of PoA, including general PoAs, financial PoAs, and special PoAs (like Arizona’s Mental Health Care PoA)

However, you may need to take an extra step to prevent confusion.

There are two areas to consider here. 

First, you may want to cross out any contradictory permissions. For example, Five Wishes provides the PoA with authority to take legal action where required, to see personal and financial files, and apply for some programs. If another person has authority for such tasks, the associated parts of Five Wishes should be crossed out.

There is also an open-ended section in the PoA part of Five Wishes.

Here, you can provide details about who does have authority and any other documents. For example, you could state that “family and friends can refer to Document X or the Financial PoA, which specifies permissions around financial matters”. You might even name the individual who does have authority for these topics. 

Other Forms

You can also attach extra information to your Five Wishe, such as additional details about wishes or even an entirely separate form. For example, the Dementia Directive can be used to provide details about dementia-specific wishes.

When to Use Five Wishes as an Advance Directive

Five Wishes is a fantastic choice in many situations. It’s especially relevant if:

• The person using the form struggles to understand the options provided by the state
• You’re trying to minimize paperwork or streamline the process
• You’re assisting a loved one with their advance planning
• There are no other signed advance directives
• You want to talk about comfort and spiritual wishes
• You can’t afford a lawyer or don’t want to use one
• There’s enough time to talk through your loved one’s wishes to make sure there are no misunderstandings

Even if you don’t fit into any of these categories, you could still see many benefits from relying on Five Wishes.

Using Five Wishes for Planning

While Five Wishes is designed as an advance directive, this isn’t the only way to use the forms. You might simply use them for planning, like in the approaches below:

• Use the Five Wishes document to get you thinking about the specific type of care you would like to receive. 
• Have an aging parent fill out Five Wishes (but not sign it), then take the document to a lawyer and use it as the starting point for a custom Living Will and/or PoA.
• Use Five Wishes to initiate a conversation about the care someone wants, to give you a better sense of their wishes.

Crucially, Five Wishes is only legally valid if signed and witnessed, so you can easily fill it out and then decide not to use it.

Complexities with Five Wishes

All advance directives have challenges and limitations. There’s no way around this, as healthcare wishes are complex and can’t ever be fully covered in a single form.

Below, we highlight some of the main complexities with Five Wishes and how you can limit their effect.

It’s crucial to note that these complexities aren’t reasons to avoid Five Wishes. You’ll run into some challenges regardless of which document you use.

It May Not Be Immediately Accepted

Five Wishes is less well-known than ‘official’ advance directives and the language may not be what everyone expects. This can lead to initial resistance in healthcare settings. Some staff could even refuse to accept Five Wishes at first, especially if they are stressed and tired.

However, Five Wishes is legally valid, so there shouldn’t be any major issues here. It will likely just require a little extra time and advocacy to get staff to recognize the paperwork.

Similar issues can happen with other paperwork anyway.

This is why it’s best to talk to staff members early – before the advance directive needs to be used. Doing allows you to answer any questions and resolve issues before there’s an urgent need.

There’s The Potential for Misinterpretation

The language of Five Wishes makes it easier to understand than most advance directives. But, this language is also less precise, which could lead to confusion or interpretation.

Thankfully, Five Wishes can be modified. You can add comments, details, or other specific scenarios to clarify your wishes and reduce the risk of confusion.

It Doesn’t Cover All Relevant Situations

Five Wishes focuses on end-of-life situations, especially when people have severe brain damage or are in a coma. It doesn’t consider times when a person may have lost decision making capacity, but do not have severe physical health issues.

The issue is easily solved here as well, by simply including additional information about any situations that are missed.

Also, there are laws and processes for times when the Living Will doesn’t provide enough details. The chosen surrogate will often need to make decisions based on their understanding of the principal’s values.

General Advance Planning Challenges

There Will Be Gaps

No matter how hard you try, an advance directive will never cover all possible situations. There’s simply too much we can’t predict, especially as different aspects of health can interact, healthcare continues to improve, and there are many human elements.

This is why you can’t just have a Living Will. It’s equally important to nominate a suitable surrogate through your Power of Attorney document. This person is responsible for interpreting your Living Will and making decisions on your behalf. The information in your Living Will and their knowledge of you will help the proxy work around any gaps.

Family Conflict

Family conflict adds another layer of complexity to any situation. It can be especially significant in end-of-life situations, as family members can have dramatically different opinions about the best way forward.

Some family members may also not trust or not even like one another. This can create some huge challenges when one such family member gets named as the healthcare proxy.

You can minimize the risk of problems by carefully choosing your healthcare proxy and explaining to everyone why that particular person was chosen. For example, you might choose someone outside the immediate family as your proxy, partly to minimize conflict and partly to give family members the chance to simply be present.

Five Wishes is less well-known and a little less precise than some other advance directives, and some family members might try to use this as leverage. But, if there’s a conflict going on, family members are going to find something to complain about no matter what.

Dementia

Finally, there’s the case of dementia. This is relevant in two different ways, depending on whether the person has been diagnosed with dementia or not.

Someone Diagnosed with Dementia

The first thing to consider is whether the person has sufficient capacity to even sign a healthcare directive. If there are doubts about this, then anything they sign can come under question. You may need to talk to their physician and a lawyer to determine the best course of action.

If there isn’t an advance directive in place, then healthcare providers will turn to the ‘next of kin’ to act as a surrogate decision maker. Each state has a specific order that defines who the next of kin is, often starting with the individual’s spouse.

Adults caring for an aging parent who has suspected or confirmed cognitive impairment may face additional hurdles in supporting them, especially with managing their finances or making legal decisions. It may be necessary to seek guardianship to obtain the authority needed to make decisions for the senior.

Dementia in the Living Will

Then there’s the Living Will itself. Many documents, including Five Wishes, don’t contain explicit information about how an individual wants to be cared for if they are diagnosed with dementia. Yet, this is a crucial area, as some people may wish for different decisions if they have dementia versus another type of health issue.

The later stages of dementia provide a good example of this issue.

As dementia progresses, the individual becomes more susceptible to health problems, including infections. Treating such issues also becomes increasingly difficult and stressful for the person with dementia, as they may not understand where they are or what’s happening. Such challenges only increase in frequency over time.

At some point, the healthcare proxy may choose to stop treating such health issues. Or, to only treat those that have simple solutions.

Anyone with strong opinions about their wishes here may want to talk about this in their Living Will. This way you can provide guidance about the decisions your proxy will be making. Doing so could make their role less stressful too. There’s even a Dementia Directive that can be attached to your Five Wishes to provide all the extra details you need.

Final Thoughts

Five Wishes is a powerful document, one that makes advance care planning much easier and less stressful. It’s perfect for seniors and their caregivers, as it is accessible in the way that few other advance directives are. 

Even if you don’t use Five Wishes as a legal advance directive, it’s still a fantastic option for beginning conversations and getting people thinking about their end-of-life wishes.