A Washington D.C. advance directive allows a person to select someone else to make health care decisions on their behalf and write end-of-life decisions. The person selected, called an agent, will be able to make medical decisions on behalf of a patient and in accordance with their wishes. The agent may only have such powers if the patient is incapacitated. An advance directive combines a medical power of attorney and living will into a single document. The form is required to be signed in the presence of two (2) witnesses for it to become in effect.
Two (2) Parts
An Advance Directive is in two (2) parts:
Part 1 – Medical Power of Attorney
Part 2 – Living Will Declaration
Part 1 Of 2 – Power Of Attorney For Health Care
(1) Washington DC Principal Identity. Before presenting the medical decisions you wish put in action when you are unable to represent yourself because of a terminal or fatal medical condition, you must identify yourself as the Washington DC Patient. As the Issuer of this paperwork, you shall assume the positions of Washington DC Principal or Declarant.
(2) DC Medical Attorney-in-Fact. Document the entire name of the Medical Attorney-in-Fact who should wield decision making authority over your health care treatment when you are formally diagnosed by a Washington DC Medical Professional as being in a state of permanent incapacitation, unconsciousness, or enduring a medical condition that will result in your death because no medical procedure or medication can effect a cure. Generally, you will need a very trustworthy and capable individual for this appointment. It is also considered a basic requirement that he or she and you have a clear and current level of communication regarding your medical care preferences.
(3) Address Of DC Medical Attorney-in-Fact.
(4) Telephone Number.
Article 1 Alternate Attorney-in-Fact
(5) DC Alternate Attorney-in-Fact Identity. Washington DC will allow you to list an Alternate DC Health Care Agent in case your choice above cannot take this role when you require representation with Physicians in the District. An Alternate Health Care Agent will not act in unison with your DC Medical Attorney-in-Fact. Instead, the DC Alternate will only have access to the health care decision-making power this document grants over your treatment when your DC Attorney-in-Fact makes it known that he or she refuses to act in this role for any reason (i.e., he or she is no longer willing, is aware of being revoked as an Agent, etc.) or cannot be contacted or located for a significant period of time. This precaution aids your efforts in making sure that you will have someone to convey your medical decisions to DC Physicians when they are sought.
(6) Address And Telephone Number
(7) 2nd Alternate Attorney-in-Fact Name. A Second Alternate DC Health Care Agent can be authorized to take over the role of your DC Medical Attorney-in-Fact at the time of your incapacitation should your First DC Alternate Agent decline the responsibility or is unable to act. Your Second DC Alternate Health Care Agent will only be approached when your DC Medical Attorney-in-Fact and First Agent have already proven ineffective for this role. This means that an additional Party, the Second Alternate health Care Agent that you appoint, will be needed. For him or her to be approached as a replacement for your previous Agents, you must attach the full name of your chosen 2nd Alternate DC Health Care Agent to this role by documenting it in the space provided.
(8) Address And Telephone Number.
(9) Statement Of Directives For Life-Prolonging Care. When you have been incapacitated by a medical condition that will leave you permanently dependent on life-support machines, life-prolonging treatment, and life-sustaining procedures and medications or if you have been diagnosed as permanently unconscious, then Washington D.C. Doctors will refer to this directive to assess where you stand with the procedures (i.e. intubation, dialysis, artificial nutrition/hydration, etc.) that will be needed to maintain your body while in such a prone state. While your DC Attorney-in-Fact should be kept up-to-date on your medical preferences at all times, it is still recommended that you set them down on paper. This will also aid, instruct, or remind your Medical Attorney-in-Fact of your treatment preferences when life-altering decisions are being sought by DC Physicians regarding your care. It should be noted that unless you indicate otherwise, your DC Medical Attorney-in-Fact will not be able to carry out treatment decisions that are contrary to your directives and statements.
(10) Special Provisions And Limitations. You may place provisions on the life-sustaining treatments you discussed, on when or how your DC Medical Attorney-in-Fact may make your treatment decisions and limitations such as denying your DC Medical Attorney-in-Fact the principal power and responsibility for certain decisions. Use the area provided to deliver any such provisions to the powers granted and limitations to the DC Attorney-in-Fact’s use of principal authority over your treatment decisions.
DC Health Care Principal Signature
(11) Signature Date. In order for the Washington DC Health Care Agents that you have named above to be able to act as your Medical Attorney-in-Fact when called upon, you will need to prove your intention by signing your name. The date of this signature must be provided at the time of your signing.
(12) Address Of Signing. The physical location where you sign this signature must be reported.
(13) DC Principal’s Signature. Sign your name before an impartial Party that can verify your act as intentional and genuine to all appearances.
Witnesses
(14) First (1st) Witness Signature. If two impartial Witnesses shall act as the source of the testimony to your signature’s authenticity, then each must attend the “Witnesses” section. The First (1st) Witness must sign his or her name.
(15) First (1st) Witness Signature Date. The First (1st) Witness must enter the current date immediately after signing the testimonial. It should be noted that all signature dates on this document should be identical.
(16) Home Address And Printed Name.
(17) Second (2nd) Witness Signature. Two Witnesses must watch you sign this document. Therefore, the Second (2nd) Witness must sign his or her name to demonstrate his or her confirmation to your own signature.
(18) Second (2nd) Witness Signature Date.
(19) Home Address And Printed Name.
Additional Witness Declaration
(20) Declaring Witness Signature And Date. At least one of the Witnesses present at the time of your signing must be wholly impartial in that he or she may not be related to you or possess the ability or knowledge that he or she is able to claim any part of your estate upon your death. This Witness must sign his or her name to the third area in the Witness’s section.
(21) Home Address And Printed Name.
Part 2 Of 2 – Living Will Declaration
(22) Formal Date Of Living Will Declaration.
(23) DC Declarant Identity. Produce your entire name to the statement made.
(24) Requesting Life-Sustaining Treatment As Needed. When you have been diagnosed with a medical condition that is permanent and incapacitating or one that will result in your death, the authorization to engage in or continue life-sustaining medications and medical procedures must be presented or withheld. To issue this authorization, initial the statement provided. This will instruct DC Doctors not to deny you life support and that any life-sustaining treatments in effect should remain so even when diagnosed with one of the aforementioned medical conditions.
(25) Withholding Or Withdrawing Life-Sustaining Treatment. If, on the other hand, you do not wish DC Doctors to begin or continue any life-support medications and procedures after being diagnosed with an incurable medical condition or as unconscious permanently, then the authorization needed by DC Doctors to deny such treatments is required. Produce your initials to the second directive statement to approve of the withholding of life-sustaining procedures when permanently afflicted with a severely debilitating or fatal medical condition.
Required Signature Action
(26) Declarant’s Signature. Sign your name once you have issued your authorization above.
(27) Calendar Date Of Signing. Deliver the current date at the time of your signature
(28) Declarant Address. Report your residential address, then turn this directive over to the Witnesses who shall verify this execution.
(29) First (1st) Witness Signature And Date. The First (1st) Witness must sign and date this document to testify to the fact that your signature was provided by you while coherent and aware of your actions.
(30) Home Address And Printed Name.
(31) Second (2nd) Witness Signature And Date. The Second (2nd) Witness will need to provide the same confirmation to your signature’s authenticity by also signing and dating this paperwork.
(32) Home Address And Printed Name.
Related Forms
Durable (Financial) Power of Attorney
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