Washington Advance Directive Form

Create a high quality document online now!

A Washington advance directive is a document that lets a person select their end-of-life health care options and choose an agent to carry them out. The form allows a person to decide whether or not they would like to receive or refrain from life-sustaining treatments. Such treatments include artificial breathing and feeding assistance. After an advance directive is written and signed, by either a notary public or two (2) witnesses, it may be used if a patient becomes incapacitated.

Table of Contents

Laws

StatuteRCW 70.122.030, RCW 11.125.090

Signing Requirements (RCW 11.125.050, RCW 70.122.030) – Two (2) witnesses or a notary public.

Versions (9)


AARP

Download: Adobe PDF

 

 

 


End of Life Washington

Download: Adobe PDF

 

 

 


Everett Clinic

Download: Adobe PDF

 

 

 


Kaiser Permanente

Download: Adobe PDF

 

 

 


Mental Health

Download: Adobe PDF, MS Word

 

 

 


Providence Health

Download: Adobe PDF

 

 

 


Spanish (Español) Version

Download: Adobe PDF

 

 

 


Swedish Health

Download: Adobe PDF

 

 

 


Washington State Medical Assoc.

Download: Adobe PDF

 

 

 

How to Write

Download: Adobe PDF

Designation Of Health Care Agent And Alternate Agents

(1) Identity Of Washington Principal. Present yourself as the Washington Health Care Principal by documenting your entire name in the appropriate statement.

(2) Washington Health Care Agent. The person you choose as your Health Care Agent or Washington Medical Attorney-in-Fact may not be Physicians, Nurses, or Health Care Personnel connected with the Facility responsible for your care. It should be someone you trust, who can be said to have your interests in mind, and respects all of your health care preferences. This is often a relative or domestic partner but can be anyone of your choosing. Declare the identity of your Washington Medical Attorney-in-Fact, otherwise known as your Health Care Agent, on the blank line requesting this information.

(3) Address And Phone Number Of Washington Health Care Agent. Include the methods needed to contact the Washington Health Care Agent by recording each piece of information requested.

(4) Washington Health Care Agent Name. The full name of the Washington Medical Attorney-in-Fact you appointed should be reproduced to make the next designation. This will be someone that you trust to take over the role of Washington Attorney-in-Fact in case it cannot be filled by your original choice when you need someone to speak for you to Washington Health Care Providers.

(5) Alternate Washington Health Care Agent. As mentioned earlier, the Alternate Washington Health Care Agent is a precaution and will not receive any authority to represent your medical interests unless your original appointment (see Item 2) does not take up this role (for any reason). If this happens and you are unconscious and unable to name another Agent to take his or her place, Washington Physicians will refer to this document then contact the Alternate Washington Health Care Agent for your treatment instructions and medical authorizations. Once it is solidified that your original Medical Attorney-in-Fact will not represent you and the Alternate Washington Health Care Agent is available, all the principal powers granted to the original Agent will automatically be transferred to your Alternate Washington Health Care Agent.

(6) Address And Phone Number Of Alternate Washington Agent.

(7) Washington Agent And Alternate Agent Name. A reproduction of the names recorded for your Washington Attorney-in-Fact and Alternate Health Care Agent is required for the next appointment’s statement.

(8) Second Alternate Washington Agent. You can identify a Successor to Washington Medical Attorney-in-Fact and the Alternate Health Care Agent should both be indisposed, unwilling, or disqualified from serving their roles as your Medical Representatives. The Second Alternate Washington Agent will only be able to take up the Washington Medical Attorney-in-Fact role when neither of the previous Parties does and you are unable to communicate. For this to happen, the directive being completed must authorize this transfer of power through the documentation of your Second Alternate Washington Health Care Agent’s full name and contact information.

Special Provisions

(9) Direct Washington Principal Instructions. Your Washington Medical Attorney-in-Fact will be given the basic power to inform Washington Physicians of your treatment preferences. Ideally, you will have additional documentation (such as a Living Will) however in the absence of this paperwork or in support of it, you may give your Washington Medical Attorney-in-Fact specific instructions on how he or she should represent you as well as fine-tune the principal authority being granted. For instance, you may not wish your Washington medical Attorney-in-Fact to have the responsibility or power to decide on whether life-prolonging care should be given or withheld when specific medical events occur but are comfortable with his or her abilities regarding other medical conditions. Utilize the space in the fourth article of this appointment to document such provisions, instructions, and/or limitations that should be used to define your Washington Medical Attorney-in-Fact’s authorized actions to represent you.

Washington Principal Signature

(10) Your Signature Date.

(11) Grantor. Identify yourself as the Signature Party delegating the authority to make medical decisions over your treatment. Print your name where requested in this appointment’s signature area.

(12) Grantor Signature. Sign your name on the same day that you recorded your signature date. Make sure that either two adults able to act as Witnesses to your signature are present or a registered Notary Public is attending.

(13) Witness To Grantor Signature. Each Witness observing the Washington Health Care Principal’s signature must sign his or her own name to the confirmation statement on display.

(14) Notary Public. The Notary Public serving to verify your act of signing as the Washington Health Care Principal will use his or her tools and notarization procedure to prove your signing authentic and fairly provided.

Health Care Directive

(15) Directive Date. As mentioned earlier, it is recommended that you set your health care and treatment wishes to paper in addition to appointing your Washington Medical Attorney-in-fact. This will be handled by the next portion of this directive. As with the appointment made above, Washington Medical Staff will seek the most recent document of this kind that you have issued. To avoid confusion and save time, deliver the formal filing date you wish associated with your instructions.

(16) Washington Declarant Name. Produce your full name to claim this directive as your own in the State of Washington.

(17) When Permanently Unconscious. The directives set in the first two statements will inform Washington Physicians that you do not wish life-prolonging treatment (i.e., intubation, life-support machines, etc.) applied in your medical care when you have an incurable medical condition or are persistently unconscious. While this is a general statement, some specific treatments will need additional definitions. The topic of receiving artificial nutrition and hydration from a machine that connects to your system using a tube or IV must be covered. If you wish Medical Staff in the State of Washington to manage your nutrition and water when you can no longer eat, drink, or absorb sustenance normally then you may approve of the use of artificial nutrition and hydration to do so by initialing the “I Want” line.

(18) Authorizing Denial Of Artificial Nutrition. To inform Washington State Health Care Providers that they are authorized to withhold or detach tubes delivering artificial nutrition and hydration to your system once you are diagnosed as being permanently incapacitated, unconscious, and/or suffering a fatal and untreatable medical condition with no cure, you must initial the “Do Not Want” line in Statement C.

(19) Additional Directions Regarding Care. If you would like to address specific treatments, amend the statements made in this document, apply conditions or circumstances to them, or convey any other useful information regarding how you wish your medical care to be handled when permanently unconscious, incognizant/unaware, or enduring a terminal medical condition that will result in death regardless of treatment efforts, then use the space in Statement G to present this information.

(20) Declarer Signature. Review the above information. If it is accurate and matches your health care goals, then sign your name. Two impartial adults must serve as Witnesses to this action however, if possible, it is recommended that you use a Notary Public to verify your act of signing (or both).

(21) Witness Confirmations. Each Witness must confirm that he or she has seen you sign this document while appearing to comprehend your actions as a Declarant signing his or her health care directives. Additionally, each must testify to being impartial by not being related to you (blood, marriage, adoption), being unable to claim any part of your estate or assets when you die, and is not employed in any way by your Health Care Provider. This confirmation must be provided by each Witness and can only be accomplished with the Witness’s signature.

(22) Notary Public. A Notary Public can be used to verify your act of executing this directive. This is sometimes preferred since it is usually easier to track down one registered Notary Public for additional statements on your signing than it is to find two Witnesses. The Notary Public will utilize the notarization procedure to verify your signature then return this document. In most cases, this process will only take a few minutes

Related Forms


Durable (Financial) Power of Attorney

Download: Adobe PDF

 

 

 


Last Will and Testament

Download: Adobe PDF, MS Word, OpenDocument