Advance Directive Forms (Page 4 of 5) in pdf

Durable Power of Attorney for Health Care

I, ___________________________(name), designate_____________________________ (name) as my

attorney in fact, to act for me if I become incapacitated. I hereby revoke any and all health care powers

of attorney previously granted by me.

1. Alternate Attorney in Fact. If for any reason _________________________(name) fails or ceases

to act, I designate ____________________________________(name), then

_______________________________(name) as alternate attorneys in fact, to serve in the order

named. An attorney in fact may resign by delivering written notice to that effect, in recordable form,

to an alternate, successor, or co-attorney in fact. In this Durable Power of Attorney for Health Care,

the “attorney in fact” means the acting attorney in fact.

2. Power to Make Health Care Decisions. My attorney in fact shall have the right to make decisions,

and to give informed consent on my behalf, as to my health care, to the extent permitted by law. This

shall include, but not be limited to, the right to consent to the withholding or withdrawal of life-

sustaining procedures that would only prolong artificially the moment of my death and prevent me

from dying naturally, in those circumstances in which a doctor(s) has determined (a) that I am in a

permanent unconscious condition, meaning an incurable or 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, or (b) that I have a terminal

condition, meaning 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 medical standards. I also authorize my attorney in fact to make decisions about the

artificial administration of food and fluids, consistent with any Health care Directive (living will) I

have executed.

3. Effectiveness. This Durable Power of Attorney for Health Care becomes effective upon my

incapacity. Incapacity shall include the inability to make health care decisions effectively for reasons

such as mental illness, mental deficiency, incompetency, physical illness or disability,advanced age,

chronic use of drugs, or chronic intoxication. Incapacity may be determined (i) by court order or (ii)

by a qualified attending doctor.

4. Duration. The Durable Power of Attorney for Health Care becomes effective as provided in Section

3 and shall remain in effect to the fullest extent permitted by Chapter 11.94 of the Revised Code of

Washington, or until revoked or terminated as provided in Section 5 or 6.

5. Revocation. This Durable Power of Attorney for Health Care may be revoked, suspended, or

terminated by written notice from me to the designated attorney in fact and, if this document has

been recorded, by recording notice of termination in the office where deeds are recorded for real

estate located in the county of filing, that being _________________ County, Washington.

6. Termination. If appointed, a guardian of my person may, with court approval, revoke, suspend, or

terminate the Durable Power of Attorney for Health Care.

7. Reliance. Any person dealing with the attorney in fact shall be entitled to rely upon the Durable

Power of Attorney for Health Care so long as the person with whom the attorney in fact was dealing,

at the time of any act taken pursuant to this Durable Power of Attorney for Health Care, had neither

actual knowledge nor written notice of revocation, suspension, or termination of this Durable Power

of Attorney for Health Care. Any action so taken, unless otherwise invalid or unenforceable shall be

binding on my heirs, devisees, legatees, or personal representatives.

8. Indemnity. My estate shall hold harmless the attorney in fact from all liability for acts or omissions

done in good faith.

Advance Directive Forms Page 4

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