Advance Directive Template
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4ADVANCE DIRECTIVE
Your Durable Power of Attorney for Health Care, Living Will and Other Wishes
This document has been prepared and distributed as an informational service of the District of Columbia
Hospital Association.
INSTRUCTIONS AND DEFINITIONS
Introduction:
This form is a combined durable power of attorney for health care and living will for use in D.C., Maryland
and Virginia. With this form, you can:
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Appoint someone to make medical decisions for you if you, in the future, are unable to ma ke those
decisions for yourself.
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Indicate what medical treatment you do or do not want if, in the future, you are unable to make
your wishes known.
Directions:
•
Read each section carefully.
•
Talk to the person you plan to appoint to make sure that he/she understands your wishes and is
willing to take the responsibility.
•
Place the initials of your name in the blank before those choices you want to make.
•
Fill in only those choices that you want under parts 1, 2 and 3. Your advance directive should be
valid fo r whatever part(s) you fill in as long as it is properly signed.
•
Add any special instructions in the blank spaces provided. You can write additional comments on
a separate piece of paper but you should indicate on the form that there are additional pages to
your advance directive.
•
Sign the form and have it witnessed.
•
Give to your family and anyone else who might be involved in your care a copy of your advance
directive and discuss it with them.
•
Understand that you may change or cancel this document at any time.
WORDS YOU NEED TO KNOW
Advance Directive: A written document that tells what a person wants or does not want if he/she in the
future can’t make his/her wishes known about medical treatment.
Artificial Nutrition and Hydration: When food and water are fed to a person through a tube.
Autopsy: An examination done on a dead body to find the cause of death.
Comfort Care: Care that helps to keep a person comfortable but does not make him/her better. Bathing,
turning, and keeping a person’s lips moist are types of comfort care.
CPR (Cardiopulmonary Resuscitation): Treatment to try to restart a persons breathing or heartbeat. CPR
may be done by pushing on the chest, by putting a tube down the throat, or by other treatment.
Durable Power of Attorney for Health Care: An advance directive that appoints someone to make
medical decisions for a person if in the future he/she can’t make his or her own medical decisions.
Life-Sustaining Treatment: Any medical treatment that is used to keep a person from dying. A breathing
machine, CPR and artificial nutrition and hydration are examples of life -sustaining treatments.
Living Will: An advance directive that tells what medical treatment a person does or does not want if
he/she is not able to make hi/her wishes known.
Organ and Tissue Donation: When a person permits his/her organs (such as eyes or kidneys) and other
parts of the body (such as skin) to be removed after death to be transplanted for use by another person or to
be used for experimental purposes.
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