Healthcare Power of Attorney - District of Columbia

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

District of Columbia

This document names a person to make health care decisions for me if I cannot make or communicate a particular decision. I may continue to make my own decisions while I can give or withhold informed consent. I may state treatments I want or do not want below. D.C. Code §§ 21-2205 to 21-2207.

1. Principal and appointment

I, [PRINCIPAL FULL NAME], of [ADDRESS], appoint [AGENT FULL NAME], of [ADDRESS], telephone [PHONE], as my attorney in fact for health care (my agent).

If that person is unavailable or unable to act, I appoint these successors in the order shown:

1. [FIRST SUCCESSOR FULL NAME], [ADDRESS], [PHONE].
2. [SECOND SUCCESSOR FULL NAME], [ADDRESS], [PHONE].

Only one agent acts at a time. A successor may act when each person listed before that successor cannot or will not act.

2. Effective time and duration

This power of attorney becomes effective upon my incapacity. For a health care decision, incapacity is certified under D.C. Code § 21-2204 by two qualified District licensed professionals, including a physician and a qualified psychologist or psychiatrist; at least one must examine me within one day before certification. The certification concerns health care decision making and is recorded in my patient care record.

This power of attorney continues during that incapacity. It does not allow my agent to override a decision for which I can give or withhold informed consent. D.C. Code § 21-2206(b)(2).

3. Agent's authority

Subject to my instructions and limits below, my agent may make health care decisions I could make under District and federal law, including granting, refusing, or withdrawing consent to health care; reviewing my health care records and receiving information needed for informed decisions; choosing or discharging health care professionals; and deciding admission to or discharge from health care facilities. D.C. Code § 21-2206(a).

My agent must follow my wishes stated here. If my wishes are unknown and cannot be found, my agent must act on a good faith belief about my best interests. D.C. Code § 21-2206(c).

4. My instructions and limits

Treatments or care I want: [WRITE INSTRUCTIONS OR "NONE STATED"]

Treatments or care I do not want: [WRITE INSTRUCTIONS OR "NONE STATED"]

Instructions about life prolonging care, artificial nutrition or hydration, comfort care, or other decisions: [WRITE INSTRUCTIONS OR "NONE STATED"]

Limits on my agent's authority: [WRITE LIMITS OR "NONE"]

Other people my agent should consult, if reasonably available: [NAMES AND CONTACT INFORMATION OR "NONE"]

These instructions do not appoint another decision maker or give anyone authority beyond this document.

5. Revocation and copies

While I have capacity to create this health care power of attorney, I may revoke my agent's appointment by notifying the agent orally or in writing, or revoke the agent's health care decision authority by notifying a health care provider orally or in writing. D.C. Code § 21-2208(a). I should tell my agent and health care providers where to find the current document.

Unless I expressly say otherwise here, this document revokes my prior durable powers of attorney for health care decisions only. D.C. Code § 21-2208(d).

Prior health care power of attorney I intend to preserve, if any: [IDENTIFY DOCUMENT OR "NONE"]

Give a copy of the signed document to my agent and, when appropriate, my health care providers. Keep the original at [LOCATION].

6. Principal's signature

I understand that this document gives my named agent authority to make health care decisions for me when I cannot make them myself. I sign it voluntarily.

Principal signature: ______________________________

Printed name: [PRINCIPAL FULL NAME]

Date: [__/__/____] Place of signing: [ADDRESS]

7. Two adult witnesses

Each witness affirms that the principal signed or acknowledged this document in the witness's presence, appeared to be of sound mind and free from duress, and that the witness is neither the appointed agent, the principal's health care provider, nor an employee of that provider. At least one witness must also complete the separate declaration below. D.C. Code § 21-2205(c)-(d).

Witness 1: Signature ______________________________ Date [__/__/____]

Printed name: [NAME] Address: [ADDRESS]

Witness 2: Signature ______________________________ Date [__/__/____]

Printed name: [NAME] Address: [ADDRESS]

Additional declaration by at least one witness: I am not related to the principal by blood, marriage, or adoption. I am not entitled to any part of the principal's estate under a current will or by operation of law.

Witness signature: ______________________________ Date [__/__/____]

Printed name: [NAME]

Source: D.C. Code § 21-2207 sample form.