Washington Living Will & Durable Power of Attorney for Health Care

HEALTH CARE DIRECTIVE

(Revised Code of Washington 70.122.030)

Part 1 of 2. This packet contains two instruments: this Health Care Directive (Washington’s statutory living will) and, beginning on its own page, a Durable Power of Attorney for Health Care under chapter 11.125 RCW. Each instrument has its own signature section; sign both.

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treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally.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: ______________________________

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(Chapter 11.125 RCW — Washington Uniform Power of Attorney Act)

Part 2 of 2. This instrument appoints a health care agent. It works together with the Health Care Directive in Part 1: your agent must follow your directive and your known wishes.

1. DESIGNATION OF HEALTH CARE AGENT

I, ________________________________________ (principal), appoint the following person as my agent (attorney in fact) to make health care decisions for me as authorized in this document:

Agent’s Full Legal Name: ______________________________________________

Address: ___________________________________________________________

Telephone: ________________________

Your agent must be a competent adult. Do not appoint your physician, your physician’s employee, or an owner, administrator, or employee of a health care or long-term care facility where you live or receive care, unless that person is your spouse, state registered domestic partner, parent, adult child, or adult sibling (RCW 11.125.400(3)).

2. SUCCESSOR AGENTS (OPTIONAL)

If my agent is not willing, able, or reasonably available to make a health care decision for me, or if I revoke my agent’s authority, I appoint the following successors, each to act alone and successively, in the order named:

First Successor — Full Legal Name: ________________________________________

Address and Telephone: _______________________________________________

Second Successor — Full Legal Name: _______________________________________

Address and Telephone: _______________________________________________

3. DURABILITY

This power of attorney and my agent’s authority are not terminated or affected by my subsequent disability or incapacity (RCW 11.125.040).

4. WHEN MY AGENT’S AUTHORITY TAKES EFFECT

Choose one by marking one box:

My agent’s authority takes effect when my attending physician determines in writing that I lack the capacity to make my own health care decisions.

My agent’s authority takes effect immediately and continues during any later incapacity.

5. AUTHORITY OF MY AGENT

My agent is authorized to make health care decisions for me: to consent, to refuse to consent, or to withdraw consent to any lawful examination, diagnosis, medication, surgery, or other treatment; to select, change, and discharge physicians and other health care providers; and to authorize my admission to, transfer between, or discharge from hospitals, nursing homes, and other health care institutions.

This authority expressly includes decisions about life-sustaining treatment: to provide, withhold, or withdraw cardiopulmonary resuscitation, assisted ventilation, dialysis, artificially provided nutrition and hydration, and other life-sustaining treatment, in a manner consistent with my Health Care Directive and my other known wishes. My agent shall always direct care that keeps me comfortable and relieves my pain.

My agent shall make decisions in accordance with my instructions and my known wishes and values. If my wishes on a decision are not known, my agent shall decide as I probably would (substituted judgment) and, if that cannot be determined, in my best interest (RCW 11.125.140(1); RCW 7.70.065).

6. ACCESS TO MY HEALTH INFORMATION (HIPAA)

When my agent’s authority is in effect, my agent is my personal representative under the federal health information privacy rules (HIPAA) and may examine, copy, and receive my health information and medical records; talk with my health care providers about my condition and care; and sign releases needed to obtain my records (RCW 11.125.400(1); RCW 70.02.130). Specially protected records (for example, certain mental health and substance-use records) remain subject to applicable law.

7. LIMITS ON MY AGENT’S AUTHORITY

My agent may not consent to my commitment to a mental health facility, or to convulsive therapy, psychosurgery, or other psychiatric procedures that restrict my freedom of movement, except as authorized by law (RCW 11.125.400(3); chapter 71.32 RCW governs mental health advance directives). My agent has no authority to make decisions under Washington’s Death with Dignity Act, chapter 70.245 RCW, which cannot be exercised through an agent (RCW 11.125.420). My agent’s authority ends when I die.

8. NOMINATION OF GUARDIAN

If a court appoints a guardian of my person, I nominate my agent (and then my successor agents, in order) to serve as my guardian (RCW 11.125.080). Appointment of a guardian does not itself end this power of attorney; unless a court orders otherwise, my agent’s health care decisions take precedence over a guardian’s.

9. REVOCATION

I revoke every power of attorney for health care and every appointment of a health care agent that I made before this document. I do not revoke any financial power of attorney or my Health Care Directive except by a separate writing. I may revoke this document at any time by notifying my agent, my successors, or my health care providers in writing. A person who relies on this document in good faith and without actual knowledge of its revocation is protected (RCW 11.125.100(5), (7)).

10. RELIANCE BY THIRD PARTIES

Health care providers and other persons may rely on this power of attorney or a copy of it until they have actual knowledge that it has been revoked or terminated. If a provider asks for confirmation, my agent may give the agent’s certification authorized by RCW 11.125.430. Washington’s acceptance and liability protections for acknowledged powers of attorney (RCW 11.125.190, 11.125.200) apply when this document is notarized, which is why notarization is recommended below.

EXECUTION

Sign and date this document. Your signature must be either acknowledged before a notary public (Option A — recommended) or attested by two competent witnesses (Option B) (RCW 11.125.050(1)).

Principal’s Signature: ____________________________________________

Print Name: ____________________________________________________

Date: _________________________

City and State: __________________________________________________

OPTION A — NOTARY ACKNOWLEDGMENT (RECOMMENDED)

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: ______________________________

OPTION B — ATTESTATION BY TWO WITNESSES

Each witness declares: I am a competent adult. I am not related to the principal or to the principal’s agent by blood, marriage, or state registered domestic partnership. I am not a home care provider for the principal or a care provider at an adult family home or long-term care facility in which the principal resides. The principal signed or acknowledged this power of attorney in my presence and at the principal’s direction or request, and I subscribe my name as a witness (RCW 11.125.050(1)).

Witness 1

Signature: ______________________________________________________

Print Name: ____________________________________________________

Witness 2

Signature: ______________________________________________________

Print Name: ____________________________________________________

If you appoint your spouse or state registered domestic partner as your agent, that appointment ordinarily ends if either of you later files for dissolution, annulment, or legal separation, unless this document says otherwise (RCW 11.125.100(2)(c), (3)).