[Health Care Directive] District of Columbia

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive health care.

2. These materials include:
   • Instructions for preparing your advance directive, please read all the instructions.
   • Your state-specific advance directive forms, which are the pages with the gray instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will guide you through the process.

3. Talk with your family, friends, and physicians about your advance Be sure the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person you have appointed to make decisions on your behalf, your family, friends, health-care providers and/or faith leaders so that the form is available in the event of an emergency.

5. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

INTRODUCTION TO YOUR DISTRICT OF COLUMBIA ADVANCE DIRECTIVE

This packet contains two legal documents that protect your right to refuse medical treatment you do not want, or to request treatment you do want, in the event you lose the ability to make decisions yourself:

The District of Columbia Durable Power of Attorney for Health Care lets you name someone to make decisions about your medical care — called an attorney in fact — if you can no longer speak for yourself. The durable power of attorney for health care is especially useful because your attorney in fact can speak for you any time you are unable to make your own medical decisions, not only at the end of life.

Your durable power of attorney for health care goes into effect when your doctor and one other qualified health professional (either a psychologist or a psychiatrist) certify that you lack sufficient mental capacity to appreciate the nature and implications of a health-care decision, make a choice regarding the alternatives presented or communicate that choice in an unambiguous manner.

The District of Columbia Declaration is the District of Columbia’s living will. It lets you state your wishes about medical care in the event that you develop a terminal condition and can no longer make your own medical decisions.

Your declaration goes into effect when your doctor and one other doctor certify that you have an incurable condition that will lead to your death, with or without the use of life- sustaining medical care, and life-sustaining procedures would serve only to postpone your death.

In addition to these advance directive documents, a District of Columbia Organ Donation Form is included in this packet.

These forms do not expressly address mental illness. If you would like to make advance care plans involving mental illness, you should talk to your physician and an attorney about a durable power of attorney.

Note: These documents will be legally binding only if the person completing them is a competent adult (at least 18 years old).

COMPLETING YOUR DISTRICT OF COLUMBIA ADVANCE DIRECTIVE FORMS

Whom should I appoint as my attorney in fact?

Your attorney in fact is the person you appoint to make decisions about your medical care if you become unable to make those decisions yourself. Your attorney in fact may be a family member or a close friend whom you trust to make serious decisions. The person you name as your attorney in fact should clearly understand your wishes and be willing to accept the responsibility of making medical decisions for you. Your attorney in fact does not have to be a lawyer.

You can appoint a second and third person as alternate attorneys in fact. The alternates will step in if the first person you name as an attorney in fact is unable, unwilling, or unavailable to act for you.

How do I make my Advance Directive Forms legal?

Each of the three forms included in this packet must be signed in the presence of two adult witnesses. Each form has its own restrictions regarding who can witness your signature.

Your signature on your durable power of attorney for health care cannot be witnessed by your attorney in fact, your health-care provider, or your health-care provider’s employees. At least one of your witnesses must be a person who is not related to you (by blood, marriage, or adoption) and who will not inherit any part of your estate.

Your signature on your declaration cannot be witnessed by a person signing on your behalf, anyone related to you (by blood, marriage, or adoption), anyone who will inherit any part of your estate, anyone directly financially responsible for your medical care, your attending doctor or an employee of your attending doctor, or an employee of a health- care facility in which you are a patient.  If you are a patient in an intermediate care or skilled care facility, one of your witnesses must be a patient advocate or ombudsman.

At least one of the witnesses to your signature on your organ donation form must be disinterested. This means that the witness should not be a person who could receive your organs or any portion of your estate.

Note: You do not need to notarize your Durable Power of Attorney for Health Care, Declaration, or Organ Donation Form.

Should I add personal instructions to my Durable Power of Attorney for Health Care or my Declaration?

One of the strongest reasons for naming an attorney in fact is to have someone who can respond flexibly as your medical situation changes and deal with situations that you did not foresee. If you add instructions to your durable power of attorney or your declaration it may help your attorney in fact carry out your wishes, but be careful that you do not unintentionally restrict your attorney in fact’s power to act in your best interest. In any event, be sure to talk with your attorney in fact about your future medical care and describe what you consider to be an acceptable “quality of life.” 

What if I change my mind?

You may revoke your durable power of attorney for health care by:

• notifying your attorney in fact orally or in writing,
• notifying your health-care provider orally or in writing, or
• executing a new durable Power of Attorney for Health Care.

If you name your spouse or domestic partner as your attorney in fact and your marriage or domestic partnership ends, your spouse’s or domestic partner’s power to act on your behalf will automatically be revoked.

You may revoke your declaration at any time, regardless of your mental condition, by:

• obliterating, burning, tearing, or otherwise destroying or defacing the document, or directing another person to do so in your presence;
• executing, or directing another person to execute, a dated and signed written revocation, which becomes effective when it is given to your doctor;
• orally revoking your declaration in the presence of a witness, 18 years or older, who must sign and date a written confirmation of your oral revocation. An oral revocation becomes effective once it is communicated to your doctor.

What other important facts should I know?

Your attorney in fact, if you appoint one, does not have authority to authorize abortion, sterilization, psycho-surgery, or convulsive therapy or behavior modification involving aversive stimuli, unless authorized by a court.

DISTRICT OF COLUMBIA DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 1 OF 4

INFORMATION ABOUT THIS DOCUMENT

This is an important legal document. Before signing this document, it is vital for you to know and understand these facts:

This document gives the person you name as your attorney in fact the power to make health-care decisions for you if you cannot make the decisions for yourself.

After you have signed this document, you have the right to make health- care decisions for yourself if you are mentally competent to do so. In addition, after you have signed this document, no treatment may be given to you or stopped over your objection if you are mentally competent to make that decision.

You may state in this document any type of treatment that you do not desire and any that you want to make sure you receive.

You have the right to take away the authority of your attorney in fact, unless you have been adjudicated incompetent, by notifying your attorney in fact or health-care provider either orally or in writing. Should you revoke the authority of your attorney in fact, it is advisable to revoke in writing and to place copies of the revocation wherever this document is located.

If there is anything in this document that you do not understand, you should ask a social worker, lawyer, or other person to explain it to you.

You should keep a copy of this document after you have signed it. Give a copy to the person you name as your attorney in fact. If you are in a health-care facility, a copy of this document should be included in your medical record.

DISTRICT OF COLUMBIA DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 2 OF 4

DISTRICT OF COLUMBIA DURABLE POWER OF ATTORNEY FOR HEALTH CARE

as my attorney in fact to make health-care decisions for me if I become unable to make my own health-care decisions. This gives my attorney in fact the power to grant, refuse, or withdraw consent on my behalf for any health-care service, treatment, or procedure. My attorney in fact also has the authority to talk to health-care personnel, get information, and sign forms necessary to carry out these decisions.

If the person named as my attorney in fact is not available or is unable to act as my attorney in fact, I appoint the following person(s) to serve in the order listed below:

DISTRICT OF COLUMBIA DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 3 OF 4

With this document, I intend to create a power of attorney for health care, which shall take effect if I become incapable of making my own health- care decisions and shall continue during that incapacity.

My attorney in fact shall make health-care decisions as I direct below or as I make known to my attorney in fact in some other way.

Statement of directives concerning life-prolonging care, treatment, services, and procedures:

DISTRICT OF COLUMBIA DURABLE POWER OF ATTORNEY FOR HEALTH CARE — PAGE 4 OF 4

WITNESSES

I declare that the person who signed or acknowledged this document is personally known to me, that the person signed or acknowledged this durable power of attorney for health care in my presence, and that the person appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as the attorney in fact by this document, nor am I the health-care provider of the principal, or an employee of the health-care provider of the principal.

(AT LEAST 1 OF THE WITNESSES LISTED ABOVE SHALL ALSO SIGN THE FOLLOWING DECLARATION.)

I further declare that I am not related to the principal by blood, marriage, adoption, or domestic partnership, and that I am not entitled to any part of the estate of the principal under a currently existing will or by operation of law. Signature:

DISTRICT OF COLUMBIA DECLARATION – PAGE 1 OF 2

being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, do declare:

If at any time I should have an incurable injury, disease or illness certified to be a terminal condition by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life- sustaining procedures are utilized and where the application of life- sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

DISTRICT OF COLUMBIA DECLARATION — PAGE 2 OF 2

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

I understand the full importance of this declaration and I am emotionally and mentally competent to make this declaration.

DISTRICT OF COLUMBIA ORGAN DONATION FORM PAGE 1 OF 1

Initial the line next to the statement below that best reflects your wishes. You do not have to initial any of the statements. If you do not initial any of the statements, your attorney for health care, proxy, or other agent, or your family, may have the authority to make a gift of all or part of your body under District of Columbia law.

You Have Filled Out Your Health-Care Directive, Now What?

1. Your durable power of attorney for health care and declaration are important legal Keep the original signed documents in a secure but accessible place. Do not put the original documents in a safe deposit box or any other security box that would keep others from having access to them.

2. Give photocopies of the signed original to your attorney in fact and alternates, doctor(s), family, close friends, clergy and anyone else who might become involved in your health If you enter a nursing home or hospital, have photocopies of your document placed in your medical records.

3. Be sure to talk to your attorney(s)-in-fact, doctor(s), clergy, family and friends about your wishes concerning medical treatment. Discuss your wishes with them often, particularly if your medical condition changes.

4. You may also want to save a copy of your form in an online personal health records application, program, or service that allows you to share your medical documents with your physicians, family, and others who you want to take an active role in your advance care planning.

5. If you want to make changes to your documents after they have been signed and witnessed, you must complete a new document.

6. Remember, you can always revoke your District of Columbia document.

7. Be aware that your District of Columbia document will not be effective in the event of a medical emergency. Ambulance and hospital emergency department personnel are required to provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive that states These directives called “prehospital medical care directives” or “do not resuscitate orders” are designed for people whose poor health gives them little chance of benefiting from CPR. These directives instruct ambulance and hospital emergency personnel not to attempt CPR if your heart or breathing should stop.

Currently not all jurisdictions have laws authorizing these orders. We suggest you speak to your physician if you are interested in obtaining one.