District of Columbia Durable Power of Attorney for Health Care, Living Will and Other Wishes Form - Free Download | Page 2
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District of Columbia Durable Power of Attorney for Health Care, Living Will and Other Wishes Form Page 2
Persistent Vegetative State: When a person is unconscious with no hope of regaining consciousness even
with medical treatment. The body may move and eyes may be open but as far as anyone can tell, the
person can’t think or respond.
Terminal Condition: An on-going condition caused by injury or illness that has no cure and from which
doctors expect the person to die even with medical treatment. Life-sustaining treatments will only prolong
a person’s dying if the person is suffering from a terminal condition.
D.C., Maryland and Virginia
ADVANCE DIRECTIVE
Your Durable Power of Attorney for Health Care,
Living Will and Other Wishes
I, ____________________ write this document as a directive regarding my medical care.
Put the initials of your name by the choices you want.
PART 1. MY DURABLE POWER OF ATTORNEY FOR HEALTH CARE
______I appoint this person to make decisions about my medical care if there ever comes
a time when I cannot make those decisions myself:
NAME_________________________________PHONE: HOME __________________WORK______________________________
ADDRESS__________________________________________________________________________________________________
____________________________________________________________________________________________________________
If the person above can’t or will not make decisions for me, I appoint this person:
NAME_________________________________PHONE :HOME___________________WORK______________________________
ADDRESS__________________________________________________________________________________________________
____________________________________________________________________________________________________________
_____I have not appointed anyone to make health care decisions for me in this or any
other document.
I want the person I have appointed, my doctors, my family, and others to be guided by
the decisions I have made below:
PART 2. MY LIVING WILL
These are my wishes for my future medical care if there ever comes a time when I can’t
make these decisions for myself.
A. These are my wishes if I have a terminal condition:
Life-Sustaining Treatments
_____ I do not want life-sustaining treatments (including CPR) started. If life-
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District of Columbia Durable Power of Attorney for Health Care, Living Will and Other Wishes Form