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Washington of witness 2: __________________________________ Print name here: __________________________________ Address: __________________________________ __________________________________ -2- Signature of witness 1: __________________________________ Print name here: __________________________________ Address: __________________________________ __________________________________ Signaturen of law, that I have no claim against the declarer, and that I am not an employee or an attending physician of the declarer or of the health care facility (if any) in which the declarer is a patient.not related to the declarer by blood or marriage, that the declarer has stated I am not mentioned in his or her will, that I am not entitled to receive any portion of the declarer's estate by operatio_____________________________________ Statement of Witnesses The declarer has been personally known to me and I believe to be capable of making health care decisions. In addition, I affirm that I am _________________ Address:_______________________________________________________________ ______________________________________________________________________ Social Security Number or Birthdate ___at ________________________ , Washington, on __________________ (date) Signature ______________________________________________________________ Printed name:_______________________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Signed __________________________ ________________________________________________________________________ ________________________________________________________________________ ___________________________wish that the remainder of my directive be implemented. In addition I make the following additional directions regarding my care (if none, write "none"): ______________________________________________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 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 ally capable and competent to make the health care decisions contained in this directive. I also understand that I may amend or revoke this directive at any time. -1- I understand that before I signand 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 mentthat the person be guided by this directive and any other clear expressions of my desires. I accept the consequences of such refusal. (Only applicable to females) If I have been diagnosed as pregnant surgical treatment and I accept the consequences from such refusal. If another person is appointed to make these decisions for me, whether through a durable power of attorney or otherwise, I request staining treatment, it is my intention that this directive shall be honored by my family and physician(s) and other health care providers as the final expression of my legal right to refuse medical orother] want tube feeding (use of a tube through the nose or abdomen for feeding a person who can't take food by mouth) In the absence of my ability to give directions regarding the use of such life suchanical efforts to restore heartbeat or breathing after they have stopped) or assisted ventilation (use of a respirator to help keep a person breathing) I do / I do not [circle one and cross out the circumstances. I request all health care providers who care for me to honor this directive. I do / I do not [circle one and cross out the other] want either cardiopulmonary resuscitation (manual or mee and cross out the other] want to have artificially provided nutrition and hydration. I understand artificially administered nutrition and hydration is a form of life-sustaining treatment in certain onable 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 do / I do not [circle onaturally. I understand "terminal condition" means an incurable and irreversible condition caused by injury, disease, or illness that would, within reasonable medical judgment cause death within a reasre 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 n declare that: If at any time I should be diagnosed or certified in writing to be in a terminal condition by the attending physician, or in a permanent unconscious condition by two physicians, and wheing 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________ __________________________________ -2- Health Care Directive Directive made this ______ day of ____________ (month, year). I, __________________________________, being of sound mind and havrint name here: __________________________________ __________________________________ Address: Address: __________________________________ __________________________________ __________________________lth care facility (if any) in which the declarer is a patient. Signature of witness 1: Signature of witness 2: __________________________________ __________________________________ Print name here: Ped to receive any portion of the declarer's estate by operation of law, that I have no claim against the declarer, and that I am not an employee or an attending physician of the declarer or of the heamaking health care decisions. In addition, I affirm that I am not related to the declarer by blood or marriage, that the declarer has stated I am not mentioned in his or her will, that I am not entitl______________________ Social Security Number or Birthdate ________________________________________ Statement of Witnesses The declarer has been personally known to me and I believe to be capable of ______ Printed name:___________________________________________________________ Address:_______________________________________________________________ ________________________________________________the provisions of Chapter 71.05 RCW; d). Sterilization. Signed at ________________________ , Washington, on __________________ (date) Signature ________________________________________________________dure given for the purpose of inducing convulsion; b). Surgery solely for the purpose of psychosurgery; c). Commitment to or placement in a treatment facility for the mentally ill, except pursuant to l serve as my guardian if the first person is unable or unwilling. The above authorization to make health care decisions does not include the following absent a court order: a). Therapy or other proce a proceeding is initiated to appoint a guardian of my person under RCW 11.88, I nominate the person designated as my first choice (on page 1) to serve as my guardian. My second choice (on page 1) wil Durable Power of Attorney for Health Care shall have no effect upon the validity of any other Power of Attorney for other purposes that I have executed or may execute in the future. In the event thation. When the Health Care Agent does not -1- have any stated desires or instructions from me to follow, he or she shall act in my best interest in making health care decisions. The existence of thisfe-sustaining treatment, which are contained in any Health Care Directive or other form of "living will" I may have executed or elsewhere, and to receive and consent to the release of medical informataw withhold or forgo medical care and treatment including artificially supplied nutrition and hydration, following and interpreting my instructions for the provision, withholding, or withdrawing of liers shall include the power to give informed consent for health care treatment when I am not capable of doing so. This includes but is not limited to consent to initiate, continue, discontinue, withdr______________________________ (City) (State) (Zip) (Phone) The powers of my attorney-in-fact under this Power of Attorney are limited to making decisions about my health care on my behalf. These pow__________ are unable or unwilling to serve, I grant these powers to _______________________________________________________________________ (Name) (Address) _____________________________________________________ (Name) (Address) _______________________________________________________________________ (City) (State) (Zip) (Phone) In the event that both ________________________ and _______________ating physicians and health personnel. In the event that __________________________ is unable or unwilling to serve, I grant these powers to ___________________________________________________________horize her or him to consult with my physicians about the possibility of my regaining the capacity to make treatment decisions and to accept, plan, stop, and refuse treatment on my behalf with the tre_____________________ (City) (State) (Zip) (Phone) as my attorney-in-fact (Health Care Agent) by granting him or her the Durable Power of Attorney for Health Care recognized in RCW 11.94.010, and autng informed consent to health care, I designate and appoint _______________________________________________________________________ (Name) (Address) __________________________________________________e decisions. and shall continue as long as the incapacity lasts or until I revoke it, whichever happens first. If my attending physician or his or her designee determines that I am not capable of givit make health care decisions for myself as determined by my attending physician or designee, such as if I am unconscious, or if I am otherwise temporarily or permanently incapable of making health carons for myself if I was capable of doing so, as recognized by RCW 11.94.010 and consistent with any existing valid Living Will or Health Care Directive. This designation becomes effective when I cannoe I intend to create a power of attorney (Health Care Agent) by appointing the person or persons designated herein to make health care decisions for me to the same extent that I could make such decisiso. Each copy should state where the original is kept, and who else has copies. You should bring a copy with you each time you are admitted to a hospital -2- Durable Power of Attorney for Health Cargency situation. Copies should be given to your close family members, physician(s), attorney, spiritual advisor, and any others who may be called upon to act on your behalf should you be unable to do care facility in which you are a patient. The original signed and witnessed copy should be kept by a designated person or in a designated place of safe keeping where they can be obtained in any emerby blood, marriage or adoption; · Entitled to any portion of your estate or have any claim on it; or · A physician attending you, a person employed by such a physician, or someone employed by a healthsign the Directive. The document must be signed by you in the presence of two witnesses. There are restrictions on who can witness the Directive. Witnesses may not be: -1- · · · · · Related to you ed health care, to review health care records, and to consent to the disclosure of healthcare records. You can limit that right in this document if you choose. You must be 18 years of age or older to in this document or my making them known in another manner. When acting under this document the Health Care Agent GENERALLY will have the same rights that you have to receive information about proposyou, the Health Care Agent will have to act consistent with your express desires or, if they are unknown, in your best interest. You may express your desires to the Health Care Agent by including themay include specific limitations in this document on the authority of the Health Care Agent to make health care decision for you. When exercising his or her authority to make health care decisions for e you agree with it. This document also provides the option of also consenting to withholding and withdrawal of artificial hydration and nutrition by inserting your initials in the box provided. You mtreatment should you become terminally ill if such treatment would only prolong the process of dying. If you do not want such treatment used, carefully read the Health Care Directive document to ensurare Agent will not be allowed to authorize "mercy killing," euthanasia or any procedure which would actually speed up the natural process of dying. Think about whether or not you want life-sustaining ed consent, to refuse to give informed consent, or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. A Health Cu retain the right to make all medical and other health care decisions. The authority of the Health Care Agent to make health care decisions for you generally will include the authority to give informf. this power is effective only when you lose the capacity to make informed health care decisions for yourself. As long as you have the capacity to make informed health care decisions for yourself, yohis document gives the person you designate as your Health Care Agent the power to make most health care decisions for you if you lose the capability to make informed health care decisions for yoursellforms.com Notice To Person Executing the Washington State Durable Power Of Attorney For Health Care This is an important legal document. Before executing this document you should know these facts: Tituation. You should also consult an attorney whenever a document is negotiated with another party. The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegarting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular s Living Will) for the State of Washington. These forms are not intended and are not a substitute for legal advice. Laws vary from time to time and from state to state. These forms should only be a staWashington State Health Care Directive And Durable Power Of Attorney For Health Care This package contains a Durable Power Of Attorney For Health Care and a Health Care Directive (sometimes known as a Washington