Form Fr-2090-Mwhc - Virginia Advance Medical Directive Page 5
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7HOW TO COMPLETE THE BASIC MARY WASHINGTON HEALTH CARE ADVANCE DIRECTIVE
The Advance Medical Directive allows you to provide direction for your health care if you become
temporarily or permanently unable to express your wishes. This is a short form of the Advance
Directive language recommended in Virginia law. There is a longer document that includes direction
about mental health care and about what to do if you protest the decisions of my Power of Attorney
after you lose capacity. You can choose to complete that form instead of this one, or you can use
another form or even write out your wishes yourself. It is a legally valid Advance Directive as long as it
is signed, dated, and witnessed by 2 people.
A. Identifying Information
Write your name on the first line as the person who is completing the Advance Directive.
B. This section enables you to name the person you would want to make health care decisions for
you if you are temporarily or permanently unable to speak for yourself. This person can be a
relative, but does not need to be related to you. It is important that you select someone who will
know your wishes, and who will be able to understand and make decisions about your health
care.
1. Fill in the name, address, and telephone number of the person you would like to make
health care decisions for you if you cannot speak for yourself and of an alternate if the
primary agent is unavailable or unable to serve. Your agent is directed to make decisions
based on your desires and preferences, your medical condition, and your beliefs and
values.
2. The next section provides a list of powers you can grant to your agent. Mark through any
you do not want.
3. If you would like to allow your Medical Power of Attorney/Agent to control your visitors, fill
in directions under #9.
4. At the bottom of the page you can give additional directions or powers to your health care
agent.
C. Health Care Instructions
1. #1 gives direction regarding the care you would want provided or withheld if you are
determined to be very close to death and medical treatment would not help you recover.
Choose the box that represents the kind of care you would want in that situation, or write
in your own instructions about what you would or would not want.
2. #2 gives you the opportunity to indicate what kind of care you would want if your
condition makes you unaware of yourself or your surroundings, and it is reasonable
certain that you will never recover this awareness even with medical treatment. Choose
the box that represents the kind of care you would want in that situation, or write in your
own instructions about want you would or would not want.
3. This section gives you an opportunity to indicate treatments you do or do not want under
certain circumstances, even if you are not terminally ill or permanently unresponsive.
Write in any directions you would like here.
D. Affirmation and Right to Revoke
1. Date and sign the document.
2. Two adult witnesses should sign and print their names. They must be 18 or over, but can
be a spouse, blood relative, or member of your health care team. You do NOT need a
notary or attorney to help complete this form.
3. Once you have completed your Advance Directive, give copies to your Health Care
Agent, family members, and doctor. Bring a copy when you come to the hospital.
4. Finally, take this opportunity to talk to your family, physician, and Health Care Agent
about your health care choices and values, so that they can best honor your wishes.
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