Here is a picture of me.

MY WISHES FOR:

How I want people to treat me.

How comfortable I want to be.

What I want my loved ones to know.

What I want my doctors and nurses to know.

Age: Date:

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MY FAMILY:

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MY WISHESThere are many things in life that are out of our hands. My Wishes gives you a way to control something very important – how you are treated if you get very sick. It is easy to do and helps you say exactly what you want.

HOW CAN MY WISHES HELP ME AND MY FAMILY?

My Wishes lets you talk with your family, friends and doctors about how you want to be treated if you become very sick.

Your family members will not have to guess what you want if you become very sick.

Your family can know what you want through My Wishes.

WHO SHOULD USE MY WISHES?My Wishes is not a legal document; this document is best used as a tool for discussion. It is intended to be used by children under the age of 18. If a child is unable to complete this document, families are encouraged to use this form to convey their wishes for their child.

CAN I CHANGE MY WISHES?Feel free to change My Wishes anytime you want; this is YOUR document. It is recommended that your My Wishes document be revised and updated every year or as your wishes change.

WHAT DO I DO WITH MY WISHES WHEN I HAVE COMPLETED IT?

This is YOUR document to share with anyone you would like. You may want to hang it in your room or show it to your family and healthcare providers so that everyone knows how you feel.

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SOME OF MY FAVORITE THINGS:

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WISH #1MY WISH FOR HOW

I WANT PEOPLE TO TREAT ME(Check any box that you would want.)

I wish to be cared for with kindness and cheerfulness.

I wish to have my hand held and to be talked to whenever possible.

I wish people would pray for me.

I wish to have my favorite things with me if possible. My favorite things are:

I wish to have pictures of my favorite people and things.

If I am very sick and may die, I wish to be:

In the hospital.

At home.

Somewhere else:

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I DON’T LIKE…

I LOVE...

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I do not want to be in pain.

I want my doctor to give me enough medicine to stop my pain, even if it makes me sleepy.

If I don’t feel good, I want my caregivers to do whatever they can to help me feel better.

These things make me feel good:

I like to be read to. These are the books I like:

I like to play games. These are my favorite games:

I like to listen to music. These are the types of music I like:

These are some things that I do not like:

WISH #2MY WISH FOR HOW

COMFORTABLE I WANT TO BE(Check any box that you would want.)

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HOW I AM MOST COMFORTABLE:

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I wish to have my family and friends know that I love them.

I wish to be forgiven for the times that I may 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.

I wish for all of my family members to be nice to each other.

I wish for my family and friends to think about what I was like before I became very sick.

I wish for my family, friends and caregivers to respect my wishes even if they do not agree with them.

I wish for help for my family and friends if they feel too sad because of my sickness or death.

Sometimes I feel scared about:

I wish my family would know that I am not afraid of:

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

If people gather to remember me, I want them to:

If I die, please have these people take care of my things:

WISH #3MY WISH FOR WHAT I WANT MY LOVED ONES TO KNOW

(Check any box that you would want.)

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MY DOCTORS AND NURSES:

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I am a very special person, and these are some of the things that I would like everyone that takes care of me to know.

I want you to call me by my name or nickname:

I want you to tell me your name, why you are here, and what you are going to do to me before you do it.

If I need a painful procedure, I would like you to use numbing cream whenever possible.

I want to be told when something may hurt me.

Whatever I tell you about me, I want you to keep private, but you can tell these people: (I understand that others may need to know if it affects my care.)

I understand that sometimes you will need to touch my body or examine me, but please respect my privacy and dignity by:

Closing the curtain.

Covering me with a gown or sheet.

Closing the door whenever possible.

I don’t mind having these people in the room when I am being examined:

If I feel angry, happy, sad, silly, scared or lonely, I would like to be able to talk to you about it.

These things make me feel safe:

I want all of my questions to be answered honestly and in words that I can understand.

I know I need time to rest and sleep, but I also want to have time to play.

These are the other things I would like you to know about me:

WISH #4WHAT I WANT MY DOCTORS

AND NURSES TO KNOW(Check any box that you would want.)

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MY STORY:

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Signature:

Date:

Additional thoughts:

(Please write your name here.)

MY WISHESSIGNATURE PAGE

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FAMILY MEMBERS, FRIENDS AND CAREGIVERS WHO HAVE READ

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Portions of My Wishes were derived from the Five Wishes advance directive, a program of Aging with Dignity. Five Wishes is a trademark of Aging with Dignity and the contents of Five Wishes are copyrighted materials of Aging with Dignity. All rights reserved. All reproductions

or uses of Five Wishes or My Wishes require permission from Aging with Dignity, P.O. Box 1661, Tallahassee, FL 32302. 850.681.2010 | FiveWishes.org | My Wishes is a copyrighted material of Central DuPage Hospital. ©2018 All rights reserved.

P.O. Box 1661 | Tallahassee, Florida 32302-1661

850.681.2010 | FiveWishes.org

TO ORDER:Call 850.681.2010 or visit FiveWishes.org to purchase more copies of My Wishes.

My Wishes is based on the Five Wishes advance directive available from the non-profit organization Aging with Dignity.

My Wishes was developed by the My Wishes subcommittee of the Pediatric Palliative Team at Central DuPage Hospital, and supported by The Central DuPage Hospital Auxiliary.

A program of

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or visit FiveWishes.org to purchased on the Five Wishes ads

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