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Statutory Health Care Directive (Washington) POA-WA 103 - Legal Forms
| Statutory Health Care Directive (Washington) Form. This is a Legal Forms form and can be used in Health Care-Living Wills Power Of Attorney . |
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WASHINGTON STATUTORY HEALTH CARE DIRECTIVE Directive to withhold or withdraw life-sustaining treatment Pursuant to RCW Section 70.122.030 any adult person may execute a directive, directing the withholding or withdrawal of lifesustaining treatment in a terminal condition or permanent unconscious condition as follows: NOTE: The Directive must be signed by two witnesses. The following persons may not serve as witnesses: (a) anyone related to the declarer by blood or marriage; (b) anyone entitled to part of the declarer's estate, by Will or otherwise; (c) anyone with a claim against the declarer's estate; (d) the declarer's attending physician or any of the physician's employees; or (e) the employees of a health facility (hospital or nursing home) in which the declarer may be a patient. Statutory Health Care Directive I, city of Washington, make this Health Care Directive this of (name), living in the , in the county of , in the State of day , 20 I, , domiciled in the State of Washington, 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treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally.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. 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) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy. 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. 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. 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. (c) (e) (f) (g) Signed Street Address City, County, and State of Residence WITNESS: The declarer is personally known to me and I believe him or her to be of sound mind. 1) Witness Address 2) Witness Address American LegalNet, Inc. © www.FormsWorkFlow.com
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