DURABLE POWER OF ATTORNEY FOR HEALTH CARE Notice to Person Executing This Document This is an important legal document. Before executing this document you should know these facts: ■ ■ ■ ■ ■ ■ This document gives the person you designate as your Health Care Agent the power to make MOST health care decisions for you if you lose the capability to make informed health care decisions for yourself. This power is effective only when you lose the capacity to make informed health care decisions for yourself. As long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions. You may include specific limitations in this document on the authority of the Health Care Agent to make health care decisions for you. Subject to any specific limitations you include in this document, if you do lose the capacity to make an informed decision on a health care matter, the Health Care Agent GENERALLY will be authorized by this document to make health care decisions for you to the same extent as you could make those decisions yourself, if you had the capacity to do so. The authority of the Health Care Agent to make health care decisions for you GENERALLY will include the authority to give informed consent, to refuse to give informed consent, or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. You can limit that right in this document if you choose. A Health Care Agent can only act under state law. “Mercy killing” is not allowed under Washington state law. A Health Care Agent will NEVER be allowed to authorize “mercy killing,” euthanasia or any procedure which would actually speed up the natural process of dying. When exercising his or her authority to make health care decisions for you when deciding on your behalf, the Health Care Agent will have to act consistent with your wishes, or if they are unknown, in your best interest. You may make your wishes known to the Health Care Agent by including them in this document or by making them known in another manner. When acting under this document the Health Care Agent GENERALLY will have the same rights that you have to receive information about proposed health care, to review health care records, and to consent to the disclosure of health care records. 1. Creation of Durable Power of Attorney for Health Care I intend to create a power of attorney (Health Care Agent) by appointing the person or persons designated herein to make health care decisions for me to the same extent that I could make such decisions for myself if I was capable of doing so, as recognized by RCW 11.94.010. This designation becomes effective when I cannot make health care decisions for myself as determined by my attending physician or designee, such as if I am unconscious, or if I am otherwise temporarily or permanently incapable of making health care decisions. The Health Care Agent’s power shall cease if and when I regain my capacity to make health care decisions. 2. Designation of Health Care Agent and Alternate Agents If my attending physician or his or her designee determines that I am not capable of giving informed consent to health care, I ______________________________________________, designate and appoint: Name __________________________________________________________ Address ____________________________________________ City ___________________________________________ State __________ Zip ____________ Phone _____________________________ as my attorney-in-fact (Health Care Agent) by granting him or her the Durable Power of Attorney for Health Care recognized in RCW 11.94.010 and authorize her or him to consult with my physicians about the possibility of my regaining the capacity to make treatment decisions and to accept, plan, stop, and refuse treatment on my behalf with the treating physicians and health personnel. In the event that _________________________________________________ is unable or unwilling to serve, I grant these powers to Name __________________________________________________________ Address ____________________________________________ City ___________________________________________ State __________ Zip ____________ Phone _____________________________ In the event that both _____________________________________________ and _______________________________________________ are unable or unwilling to serve, I grant these powers to Name __________________________________________________________ Address ____________________________________________ City ___________________________________________ State __________ Zip ____________ Phone _____________________________ Your name (print)______________________________________ 3. General Statement of Authority Granted. My Health Care Agent is specifically authorized to give informed consent for health care treatment when I am not capable of doing so. This includes but is not limited to consent to initiate, continue, discontinue, or forgo medical care and treatment including artificially supplied nutrition and hydration, following and interpreting my instructions for the provision, withholding, or withdrawing of life-sustaining treatment, which are contained in any Health Care Directive or other form of “living will” I may have executed or elsewhere, and to receive and consent to the release of medical information. When the Health Care Agent does not have any stated desires or instructions from me to follow, he or she shall act in my best interest in making health care decisions. The above authorization to make health care decisions does not include the following absent a court order: (1) Therapy or other procedure given for the purpose of inducing convulsion; (2) Surgery solely for the purpose of psychosurgery; (3) Commitment to or placement in a treatment facility for the mentally ill, except pursuant to the provisions of Chapter 71.05 RCW; (4) Sterilization. I hereby revoke any prior grants of durable power of attorney for health care. 4. Special Provisions ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ DATED this _______________________ day of _______________________ , ______________ . (Year) GRANTOR __________________________________________ STATE OF WASHINGTON ) )ss. (COUNTY OF ________________________ ) I certify that I know or have satisfactory evidence that the GRANTOR, ___________________________________________________________ signed this instrument and acknowledged it to be his or her free and voluntary act for the uses and purposes mentioned in the instrument. DATED this _______________________ day of _______________________ , ______________ . (Year) _____________________________________________________________________ NOTARY PUBLIC in and for the State of Washington, residing at _____________________________________________________________ My commission expires __________________________________________________ HEALTH CARE DIRECTIVE Directive made this _______________________________ day of _________ , ______________ . (Year) I, _____________________________________________ being of sound mind, willfully, and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare that: (A) If at any time I should have an incurable and irreversible condition certified to be a terminal condition by my attending physician, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I understand “terminal condition” means an incurable and irreversible condition caused by injury, disease or illness that would, within reasonable medical judgment, cause death within a reasonable period of time in accordance with accepted medical standards. (B) If I should be in an irreversible coma or persistent vegetative state, or other permanent unconscious condition as certified by two physicians, and from which those physicians believe that I have no reasonable probability of recovery, I direct that life-sustaining treatment be withheld or withdrawn. (C) If I am diagnosed to be in a terminal or permanent unconscious condition, [Choose one] I want _________ do not want _________ artificially administered nutrition and hydration to be withdrawn or withheld the same as other forms of life-sustaining treatment. I understand artificially administered nutrition and hydration is a form of life-sustaining treatment in certain circumstances. I request all health care providers who care for me to honor this directive. (D) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family, physicians and other health care providers as the final expression of my fundamental right to refuse medical or surgical treatment, and also honored by any person appointed to make these decisions for me, whether by durable power of attorney or otherwise. I accept the consequences of such refusal. (E) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy. (F) I understand the full import of this directive and I am emotionally and mentally competent to make this directive. I also understand that I may amend or revoke this directive at any time. (G) I make the following additional directions regarding my care: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ Signed: _______________________________________ The declarer has been personally known to me and I believe him or her to be of sound mind. In addition, I am not the attending physician, an employee of the attending physician or health care facility in which the declarer is a patient, or any person who has a claim against any portion of the estate of the declarer upon the declarer’s decease at the time of the execution of the directive. Witness: __________________________________ Witness: __________________________________ What to do with these forms Copies of the Health Care directive (Living Will) and the Durable Power of Attorney for Health Care should be given to your physician to be included in your medical record, to any person to whom you give your durable power of attorney, including any successor agents you may have named, and to your personal attorney. The originals should be kept by a designated person or in a designated place where they can be obtained in any emergency situation. For further information These forms have been provided to you as a public service by the Washington State Medical Association. Any legal questions you may have about the execution or operation of a Durable Power of Attorney for Health Care should be directed to a lawyer.
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