Washington Statutory Health Care Directive

HEALTH CARE DIRECTIVE

(Revised Code of Washington 70.122.030)

This is Washington's statutory Health Care Directive (living will) under RCW 70.122.030. It records your directions about life-sustaining treatment if you are later diagnosed in a terminal condition or a permanent unconscious condition. It does not appoint a health care agent. For an agent plus this directive in one packet, see the separate Washington Living Will & Durable Power of Attorney for Health Care product.

Directive made this ____ day of ____________ (month, year).

I, ________________________________________, having the capacity to make health care decisions, 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 be diagnosed in writing to be in a terminal condition by the attending physician, or in a permanent unconscious condition by two physicians, 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treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally.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 by using this form that a 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, and where the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand in using this form that a permanent unconscious condition means an incurable and irreversible condition in which I am medically assessed within reasonable medical judgment as having no reasonable probability of recovery from an irreversible coma or a persistent vegetative state.

(b) In the absence of my ability to give directions regarding the use of such life-sustaining treatment, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and I accept the consequences of such refusal. If another person is appointed to make these decisions for me, whether through a durable power of attorney or otherwise, I request that the person be guided by this directive and any other clear expressions of my desires.

(c) If I am diagnosed to be in a terminal condition or in a permanent unconscious condition (check one):

☐ I DO want to have artificially provided nutrition and hydration.

☐ I DO NOT want to have artificially provided nutrition and hydration.

(d) I understand the full import of this directive and I am emotionally and mentally capable to make the health care decisions contained in this directive.

(e) I understand that before I sign this directive, I can add to or delete from or otherwise change the wording of this directive and that I may add to or delete from this directive at any time and that any changes shall be consistent with Washington state law or federal constitutional law to be legally valid.

(f) It is my wish that every part of this directive be fully implemented. If for any reason any part is held invalid it is my wish that the remainder of my directive be implemented.

Signed: __________________________________________________

City, County, and State of Residence: ______________________________________

WITNESSES

The declarer has been personally known to me or has provided proof of identity and I believe him or her to be capable of making health care decisions.

Witness: _______________________________________________________

Witness: _______________________________________________________

EXECUTION UNDER RCW 70.122.030(1): sign this directive either (1) before two witnesses who are not related to you by blood or marriage, who are not entitled to any portion of your estate by will or by operation of law, who are not your attending physician or an employee of your attending physician or of a health facility in which you are a patient, and who have no claim against your estate; or (2) with your signature acknowledged before a notary public or other individual authorized by law to take acknowledgments (optional certificate below). Give a copy of the signed directive to your physician; it becomes part of your medical records.

NOTARIAL ACKNOWLEDGMENT (OPTIONAL)

Use this certificate only if you choose acknowledgment before a notary instead of the two witnesses above (RCW 70.122.030(1)).

State of Washington )

County of ______________________________ )

I certify that I know or have satisfactory evidence that ________________________________ 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: ______________________________

Notary Public Signature: _____________________________________________

Print Name: ________________________________________________

My commission expires: ______________________________