District of Columbia Advance Health Care Directive Form 2

ADVANCE DIRECTIVE
Your Durable Power of Attorney for Health Care, Living Will and Other Wishes
This document has been prepared and distributed as an informational service of the District of Columbia
Hospital Association.
INSTRUCTIONS AND DEFINITIONS
Introduction:
This form is a combined durable power of attorney for health care and living will for use in D.C., Maryland
and Virginia. With this form, you can:
• Appoint someone to make medical decisions for you if you, in the future, are unable to ma ke those
decisions for yourself.
• Indicate what medical treatment you do or do not want if, in the future, you are unable to make
your wishes known.
Directions:
• Read each section carefully.
• Talk to the person you plan to appoint to make sure that he/she understands your wishes and is
willing to take the responsibility.
• Place the initials of your name in the blank before those choices you want to make.
• Fill in only those choices that you want under parts 1, 2 and 3. Your advance directive should be
valid fo r whatever part(s) you fill in as long as it is properly signed.
• Add any special instructions in the blank spaces provided. You can write additional comments on
a separate piece of paper but you should indicate on the form that there are additional pages to
your advance directive.
• Sign the form and have it witnessed.
• Give to your family and anyone else who might be involved in your care a copy of your advance
directive and discuss it with them.
• Understand that you may change or cancel this document at any time.
WORDS YOU NEED TO KNOW
Advance Directive: A written document that tells what a person wants or does not want if he/she in the
future can’t make his/her wishes known about medical treatment.
Artificial Nutrition and Hydration: When food and water are fed to a person through a tube.
Autopsy: An examination done on a dead body to find the cause of death.
Comfort Care: Care that helps to keep a person comfortable but does not make him/her better. Bathing,
turning, and keeping a person’s lips moist are types of comfort care.
CPR (Cardiopulmonary Resuscitation): Treatment to try to restart a persons breathing or heartbeat. CPR
may be done by pushing on the chest, by putting a tube down the throat, or by other treatment.
Durable Power of Attorney for Health Care: An advance directive that appoints someone to make
medical decisions for a person if in the future he/she can’t make his or her own medical decisions.
Life-Sustaining Treatment: Any medical treatment that is used to keep a person from dying. A breathing
machine, CPR and artificial nutrition and hydration are examples of life -sustaining treatments.
Living Will: An advance directive that tells what medical treatment a person does or does not want if
he/she is not able to make hi/her wishes known.
Organ and Tissue Donation: When a person permits his/her organs (such as eyes or kidneys) and other
parts of the body (such as skin) to be removed after death to be transplanted for use by another person or to
be used for experimental purposes.
Persistent Vegetative State: When a person is unconscious with no hope of regaining consciousness even
with medical treatment. The body may move and eyes may be open but as far as anyone can tell, the
person can’t think or respond.
Terminal Condition: An on-going condition caused by injury or illness that has no cure and from which
doctors expect the person to die even with medical treatment. Life-sustaining treatments will only prolong
a person’s dying if the person is suffering from a terminal condition.
D.C., Maryland and Virginia
ADVANCE DIRECTIVE
Your Durable Power of Attorney for Health Care,
Living Will and Other Wishes
I,
____________________ write this document as a directive regarding my medical care.
Put the initials of your name by the choices you want.
PART 1. MY DURABLE POWER OF ATTORNEY FOR HEALTH CARE
______I appoint this person to make decisions about my medical care if there ever comes
a time when I cannot make those decisions myself:
NAME_________________________________PHONE: HOME __________________WORK______________________________
ADDRESS__________________________________________________________________________________________________
____________________________________________________________________________________________________________
If the person above can’t or will not make decisions for me, I appoint this person:
NAME_________________________________PHONE :HOME___________________WORK______________________________
ADDRESS__________________________________________________________________________________________________
____________________________________________________________________________________________________________
_____I have not appointed anyone to make health care decisions for me in this or any
other document.
I want the person I have appointed, my doctors, my family, and others to be guided by
the decisions I have made below:
PART 2. MY LIVING WILL
These are my wishes for my future medical care if there ever comes a time when I can’t
make these decisions for myself.
A. These are my wishes if I have a terminal condition:
Life-Sustaining Treatments
_____ I do not want life-sustaining treatments (including CPR) started. If life-
sustaining treatments are started, I want them stopped.
_____ I want life-sustaining treatments that my doctors think are best for me.
_____ Other wishes: ___________________________________________________
Artificial Nutrition and Hydration
_____ I do not want artificial nutrition and hydration started if it would be the main
treatment keeping me alive. If artificial nutrition and hydration is strated, I want it
stopped.
______ I want artificial nutrition and hydration even if it is the main treatment
keeping me alive.
______ Other wishes: __________________________________________________
Comfort Care
______ I want to be kept as comfortable and free of pain as possible, even if such
care prolongs my dying or shortens my life.
______ Other wishes: __________________________________________________
B. These are my wishes if I am ever in a persistent vegetative state:
Life-Sustaining Treatments
_______ I do not want life-sustaining treatments (including CPR) started. If lifesustaining treatments are started, I want them stopped.
_______ I want life-sustaining treatments that my doctors think are best for me.
_______ Other wishes:__________________________________________________
Artificial Nutrition and Hydration
_______ I do not want artificial nutrition and hydration started if it would be the main
treatment keeping me alive. If artificial nutrition and hydration is started, I want it
stopped.
_______ I want artificial nutrition and hydration even if it is the main treatment
keeping me alive.
_______ Other wishes:__________________________________________________
Comfort Care
_______ I want to be kept as comfortable and free of pain as possible even if such
care prolongs my dying or shortens my life.
_______ Other wishes: __________________________________________________
C. Other Directions
You have the right to be involved in all decisions about your medical care, even those
not dealing with terminal conditions or persistent vegetative states. If you have
wishes not covered in other parts of this document please indicate them here:
________________________________________________________________________
________________________________________________________________________
PART 3. OTHER WISHES
A. Organ Donation
_______ I do not wish to donate any of my organs or tissues.
_______ I want to donate all of my organs and tissues.
_______ I only want to donate these organs and tissues:________________________
_______ Other wishes:__________________________________________________
Autopsy
_______ I do not want any autopsy.
_______ I agree to an autopsy if my doctors wish it.
_______ Other wishes:__________________________________________________
If you wish to say more about any of the above choices, or if you have any other
statements to make about your medical care, you may do so on a separate sheet of paper.
If you do so, put here the number of pages you are adding:____
PART 4. SIGNATURE
You and two witnesses must sign this document for it to be legal.
A. Your Signature
By my signature below I show that I understand the purpose and the effect of this
document.
NAME________________________________________________________________________DATE____________________
ADDRESS___________________________________________________________________________
B. Your Witnesses’ Signature
I believe the person who has signed this advance directive to be of sound mind, that
he/she signed or acknowledged this advance directive in my presence, and that he/she
appears not be acting under pressure, duress, fraud or undue influence. I am not
related to the person making this advance directive by blood, marriage or adoption,
nor, to the best of my knowledge am I named in his/her will. I am not the person
appointed in this advance directive. I am not a health care provider or an employee
of health care provider who is now, or ahs been in the past, responsible for the care of
the person making this advance directive.
Witness#1
NAME_______________________________________________________________________DATE____________________
ADDRES_______________________________________________________________________________________________
Witness#2
NAME_______________________________________________________________________DATE____________________
ADDRESS_____________________________________________________________________________________________