ADVANCE HEALTH CARE DIRECTIVE

(Living Will & Durable Power of Attorney for Health Care)

District of Columbia

[// GUIDANCE: This template is drafted for use in the District of Columbia under the Health-Care Decisions Act, D.C. Code § 21-2201 et seq. Review all bracketed placeholders and optional clauses for client-specific customization. Remove guidance comments before final execution.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
   3.1 Appointment of Health-Care Agent
   3.2 Alternate Agent(s)
   3.3 Health-Care Instructions (Living Will)
   3.4 Anatomical Gift & Disposition of Remains
   3.5 HIPAA Authorization
   3.6 Nomination of Guardian/Conservator (Optional)
4. Representations & Warranties
5. Covenants & Restrictions of Agent
6. Default, Exculpation & Remedies
7. Risk Allocation
   7.1 Indemnification of Providers
   7.2 Limitation of Liability
8. Revocation & Amendment Procedures
9. Governing Law; Dispute Resolution
10. General Provisions
11. Execution Block
    11.1 Declarant Signature
    11.2 Witness Attestation (Required)
    11.3 Optional Notarial Acknowledgment

1. DOCUMENT HEADER

This Advance Health Care Directive (the “Directive”) is made this __ day of ____, 20__ (the “Effective Date”) by [DECLARANT FULL LEGAL NAME], residing at [ADDRESS] (the “Declarant”), pursuant to the District of Columbia Health-Care Decisions Act, D.C. Code § 21-2201 et seq.

2. DEFINITIONS

“Act” – The District of Columbia Health-Care Decisions Act, D.C. Code § 21-2201 et seq.

“Agent” – The individual designated in Section 3.1 to make health-care decisions for the Declarant.

“Alternate Agent” – The successor agent(s) designated in Section 3.2.

“Health-Care Decision” – Any decision regarding the Declarant’s medical treatment, placement, services, or procedures, including withdrawal or withholding of life-sustaining treatment.

“Life-Sustaining Treatment” – Any medical intervention that serves only to prolong the process of dying where, in reasonable medical judgment, death is imminent.

“Provider” – Any individual or entity duly licensed to provide health-care services.

3. OPERATIVE PROVISIONS

3.1 Appointment of Health-Care Agent

a. Designation. The Declarant hereby appoints [PRIMARY AGENT NAME], whose contact information is [ADDRESS, PHONE, EMAIL], as Agent with full authority to make any and all Health-Care Decisions on the Declarant’s behalf whenever the Declarant is determined to lack capacity under the Act.

b. Scope of Authority. Subject to Section 3.3 and applicable law, the Agent’s authority includes, without limitation, the right to:
i. Give informed consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure, including artificial nutrition and hydration;
ii. Select or discharge health-care providers and institutions;
iii. Approve or disapprove diagnostic tests, surgical procedures, and medication;
iv. Authorize admission to or discharge from a nursing home, hospice, or hospital;
v. Access and disclose medical records consistent with Section 3.5 (HIPAA Authorization).

c. Effectiveness. The Agent’s authority becomes effective upon a determination under the Act that the Declarant lacks capacity, unless the Declarant initial(s) the following optional clause:

[ ] Immediate Authority – My Agent’s authority is effective immediately and continues notwithstanding my later incapacity.

3.2 Alternate Agent(s)

If the Primary Agent is unwilling, unable, or unavailable to act, the Declarant appoints the following Alternate Agent(s) in the order named:
1. [ALTERNATE AGENT #1 NAME & CONTACT]
2. [ALTERNATE AGENT #2 NAME & CONTACT]

3.3 Health-Care Instructions (Living Will)

[// GUIDANCE: Select one or customize.]

a. End-of-Life Care. If I am terminally ill or permanently unconscious and there is no reasonable expectation of recovery:
(i) [ ] I direct that life-sustaining treatment be withheld or withdrawn.
(ii) [ ] I direct that life-sustaining treatment continue.

b. Artificial Nutrition & Hydration.
(i) [ ] I do NOT want artificial nutrition or hydration if it would only prolong dying.
(ii) [ ] I DO want artificial nutrition or hydration.

c. Pain Relief. I desire adequate pain relief even if it may hasten death, except: [SPECIFY LIMITATIONS OR “None”].

d. Other Instructions. [INSERT ADDITIONAL TREATMENT PREFERENCES]

3.4 Anatomical Gift & Disposition of Remains

(Choose all that apply)
[ ] I make an anatomical gift of any needed organs or tissues for transplantation, therapy, research, or education.
[ ] Specific gift limitations: [DETAIL]
[ ] I direct that my remains be: [BURIAL / CREMATION / OTHER].

3.5 HIPAA Authorization

Pursuant to 45 C.F.R. § 164.502(g), I authorize my Agent and Alternate Agent(s) to obtain, review, and disclose my protected health information to the extent necessary to carry out their duties. This authorization shall survive my death to the extent permitted by law.

3.6 Nomination of Guardian/Conservator (Optional)

If a court deems a guardian or conservator necessary, I nominate my Agent (or Alternate Agent if the Agent cannot serve).

4. REPRESENTATIONS & WARRANTIES

1. Capacity. The Declarant represents that, as of the Effective Date, the Declarant is of sound mind and acting voluntarily.
2. Supremacy. The Declarant warrants that no other advance directive inconsistent with this Directive is in effect, or if any exists, it is hereby revoked pursuant to Section 8.

5. COVENANTS & RESTRICTIONS OF AGENT

1. Fiduciary Duty. The Agent shall act in good faith, consistent with the Declarant’s stated wishes, religious or moral beliefs, and best interests.
2. Record-Keeping. Upon request of a Provider, the Agent shall furnish copies of relevant portions of this Directive or other documentation reasonably necessary to confirm authority.
3. Delegation. The Agent may not delegate decision-making authority except as expressly provided herein or by law.

6. DEFAULT, EXCULPATION & REMEDIES

1. Good-Faith Reliance. No Agent or Provider acting in good faith reliance on this Directive shall incur criminal or civil liability or be deemed to have engaged in unprofessional conduct.
2. Judicial Relief. Interested persons may petition the Superior Court of the District of Columbia for injunctive or other equitable relief to address alleged violations of this Directive.
3. Attorney Fees. The court may, in its discretion, award reasonable attorney fees and costs to the prevailing party.

7. RISK ALLOCATION

7.1 Indemnification of Providers

The Declarant, on behalf of his or her estate, indemnifies Providers for any loss, damage, or expense arising from good-faith compliance with this Directive, except for gross negligence or willful misconduct.

7.2 Limitation of Liability

Agents and Providers acting under this Directive shall be liable only for actions constituting bad faith, gross negligence, or intentional misconduct.

8. REVOCATION & AMENDMENT PROCEDURES

1. Methods of Revocation. This Directive may be revoked at any time by:
   a. A signed, dated written revocation;
   b. An oral or other expression of intent to revoke, in the presence of a witness 18 years of age or older; or
   c. Destruction of the original Directive by the Declarant or at the Declarant’s direction.

2. Effectiveness of Revocation. Revocation is effective upon communication to the Agent or a Provider. Providers must document receipt of the revocation in the medical record.

3. Amendments. Any amendment shall follow the same execution formalities as this Directive.

9. GOVERNING LAW; DISPUTE RESOLUTION

This Directive is governed by the laws of the District of Columbia. To the extent any dispute arises concerning its interpretation or application, exclusive jurisdiction shall lie with the Superior Court of the District of Columbia.

10. GENERAL PROVISIONS

1. Copies. Photocopies, facsimiles, or electronically transmitted copies of this executed Directive shall be as valid as the original.
2. Severability. If any provision is held invalid, the remaining provisions shall remain in full force and effect.
3. Integration. This Directive constitutes the entire advance directive of the Declarant and supersedes all prior inconsistent directives.
4. Amendment & Waiver. No amendment or waiver is effective unless executed with the same formalities as this Directive.
5. Counterparts; Electronic Signatures. This Directive may be executed in counterparts and by electronic signature to the fullest extent permitted by law.

11. EXECUTION BLOCK

11.1 Declarant Signature

I, [DECLARANT NAME], being of sound mind and acting voluntarily, execute this Advance Health Care Directive on the Effective Date written above.

Signature of Declarant

Printed Name

11.2 Witness Attestation (Two Witnesses Required)

We, the undersigned, declare that we are at least 18 years of age, not appointed herein as Agent or Alternate Agent, not related to the Declarant by blood, marriage, or adoption, not entitled to any portion of the Declarant’s estate, and not directly involved in the Declarant’s health-care provision. We witnessed the Declarant sign or acknowledge this Directive and affirm that, to the best of our knowledge, the Declarant is of sound mind and under no duress.

Witness #1:
______ Date: ____
Signature

Printed Name

Address

Witness #2:
______ Date: ____
Signature

Printed Name

Address

11.3 Optional Notarial Acknowledgment

District of Columbia, ss:

On this ___ day of ____, 20__, before me, the undersigned notary public, appeared [DECLARANT NAME], personally known to me (or proved to me on the basis of satisfactory evidence) to be the individual whose name is subscribed to this instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public
My commission expires: ____

[// GUIDANCE:
1. Provide fully executed copies to the Agent, Alternate Agent(s), primary care physician, and any relevant medical facility.
2. Encourage the client to register the Directive with any applicable electronic registry.
3. Review and update the Directive periodically, especially after major life events or changes in health status. ]