DailyAfirmation (dailyafirmation) wrote,
DailyAfirmation
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John Martin's Five Wishes

Today, I completed my Five Wishes form, which provides for:

  1. The person I want to make care decisions for me when I can't
  2. The kind of medical treatment I want or don't want
  3. How comfortable I want to be
  4. How I want people to treat me
  5. What I want my loved ones to know

This wonderful form, and gift to your survivors and potential caretakers, can be obtained from Aging With Dignity.



Wish 1—The person I want to make health care decisions for me when I can't make them for myself.

I have listed the same two people who are on my Durable Health Care Power of Attorney, though my understanding is that just listing them in this Five Wishes document is the equivalent (in most states) of having said power of attorney.

My sister is my first choice for my Durable Health Care Power of Attorney. My ex-wife is my second choice.



Wish 2—My wish for the kind of medical treatment I want or don't want.

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 delay the moment of my death (Choose one of the following–my choice indicated in green.):
  • I want to have life-support treatment.
  • I do not want life-support treatment. If it has been started, I want it stopped.
  • 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.

In a coma and 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 delay the moment of my death (Choose one of the following–my choice indicated in green.):
  • I want to have life-support treatment.
  • I do not want life-support treatment. If it has been started, I want it stopped.
  • 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.

Permanent and severe brain damage and 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, but I can not speak or understand) and I am not expected to get better, and life-support treatment would only delay the moment of my death (Choose one of the following–my choice indicated in green.):
  • I want to have life-support treatment.
  • I do not want life-support treatment. If it has been started, I want it stopped.
  • 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.




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 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 care givers to do whatever they can to help me.

  • I wish to have a cool moist 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.




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 faith community 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.




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 and friends 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, friends, and others know that I forgive them for when they may have hurt me in my life.

  • I wish for my family and friends to know that I do not fear death itself. I think it is not the end, but a new beginning for me.

  • I wish for all of my family ember 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 became seriously ill. I want them to remember me in this way after my death.

  • I wish for my family and friends and caregivers to respect my wishes even if they don't agree with them.

  • 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.

  • After my death I would like my body to be cremated.

  • My body or remains should be put in the following location: Nowhere where there will be any kind of perpetual care fee.

  • The following person knows my funeral wishes: They are on my home page on the Internet. :-)

If anyone asks how I want to be remembered, please say the following about me: He felt himself beloved on this earth. He loved his life.

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 request that you have): This is all laid out in My Last Wishes.

(Please use the space below for any other wishes. For example, you may want to donate any or all parts of your body when you die. Please attach a separate sheet of paper if you need more space.)

I am an organ donor. It's indicated on my NC Driver's License—any and all organs needed.

I have a pre-paid cremation plan with the Cremation Society of the Carolinas.




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Tags: accomplishments, death, health, sharing is caring
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