Washington Living Will Form

Washington Living Will.pdf Washington Living Will.doc The living form allows a resident of Washington State to choose their medical treatments if they cannot speak for themselves at a later time.




1. What is a living will?
A living will is a paper that tells your doctors
or others providing your health care when
you want them to stop life-sustaining medical
treatment and let you die. It can take effect in
only two situations: either if you are terminally
ill and will die soon, so that life-sustaining
procedures would only prolong the process of
dying, or if you are in a permanent
unconscious condition. Living wills (also
called ”health care directives,” “advance
directives” or “directives to physicians”) are
authorized by Washington law.
Life-sustaining procedures affected by a living
will may include manual or mechanical efforts
to restore heartbeat or breathing after they
have stopped (called ”cardiopulmonary
resuscitation” or ”CPR”) or the use of a
mechanical device (called a ”respirator”) to
keep a person breathing. These are only two
Procedures needed to ease pain are not
affected by a living will – a person with a
living will can still expect to be given
treatment needed to ease pain.
2. What is a health care power of
A health care power of attorney allows
someone you appoint to make medicaltreatment decisions for you if you are no
longer able to make them yourself. It need not
be limited to decisions about life-sustaining
treatment; it can also apply to other kinds of
medical decisions. A living will can be
combined with a health care power of
Guided by your living will, the person you
appoint can address issues that are not
specifically mentioned, and may not have
been considered, when you signed the living
will. The living will form attached to this
leaflet contains a paragraph (#6) that you can
use to give someone a health care power of
attorney. It is written to take effect if you are
no longer able to make medical-treatment
decisions for yourself. If you want to use the
attached living will form, but do not want to
give anyone a health care power of attorney,
you can simply cross out that paragraph.
Columbia Legal Services and the Northwest
Justice Project have a pamphlet available that
explains powers of attorney more generally. It
has forms that apply to financial decisions as
well as medical-treatment decisions. The
pamphlet is available on the web site of the
Northwest Justice Project – www.nwjustice.org .
(Click “self help resources” on the home page;
then click “senior citizens” on the self help
resources page; finally, on the senior citizens
page, under the heading “Other Senior Citizen QUESTIONS AND ANSWERS ON LIVING WILLS
Information,” click “Questions & Answers on
Powers of Attorney.”)
3. How can I prepare a living will and
what should it say?
A living will form that includes a health care
power of attorney provision is attached.
We have tried to design a form that would be
useful for many people. But no standard form
will be satisfactory for everyone. If you have
questions about the form, or if you want to say
something different from what is said in it,
you may wish to talk with a lawyer.
You may also wish to discuss the subject of
living wills with your doctor before you
prepare one, to help you understand what
kinds of medical decisions might be affected
by a living will. (If you sign a living will, you
may, in any case, wish to discuss it with your
doctor after you sign it, so that he or she will
understand your wishes. Some doctors or
other health care providers are unwilling to
withdraw life-supporting treatment in some
circumstances, even though withdrawal is
directed by a living will and permitted by law.
If your living will contains provisions that
your health care provider will not follow, it is
desirable to know this in advance so that you
can consider alternatives.)
Among people who want to use living wills,
there are differing views about whether food
or water should be given artificially (by tube
or intravenously) when other life-sustaining
treatment is stopped. The attached form has
places for you to make a specific choice about
both food and water.
4. How must a living will be signed?
To be valid, a living will must be dated and
signed in the presence of two witnesses. Both
witnesses must also sign. The witnesses may
not be: (a) related to you by blood or marriage;
(b) entitled to inherit money or property from
you if you die; (c) people you owe money; (d)
your attending doctor or the doctor’s
employee; or (e) an employee of a health
facility where you are a patient. A living will
does not need to be witnessed by a notary.
5. What should I do with a signed living
It is a good idea to sign two copies of the
living will. Keep one for your own records.
Give one to your doctor or health care facility
and ask that it be kept with your medical
It is also a good idea to show your living will
to, and discuss it with, family members or
friends who are likely to be looked to for
assistance if your health fails. They are more
likely to help assure that your wishes are
followed if they have a clear understanding of
your wishes.
6. What if I change my mind?
A living will may be cancelled at any time. It
• by physically destroying the document, or
authorizing someone else to do so in your
• by a written cancellation that is signed
and dated; or
• by orally telling your doctor that you
wish to cancel the living will.
6. What if I move to another state?
There are many similarities and some
differences among the living will laws in
different states. It is likely that a living will
that is valid in Washington will also be valid
in another state. However, if you move to
another state, or spend an extended period of
time in another state, it may be wise to
consult someone in that state about laws that
apply there.
Additional information about living wills:
The Washington State Department of Social &
Health Services also has a pamphlet about
living wills, entitled It is available on the
DSHS web site at www.aasa.dshs.wa.gov (select
“publications”) or by writing to DSHS
Warehouse, P.O. Box 45816, Olympia, WA
98504-5816, and asking for “DSHS 22-015(X).”
In addition to the English-language version,
the publication is available in Cambodian,
Korean, Laotian, Russian, Spanish and
Living Will 9-02 (9-17-02)
Prepared by
COLUMBIA LEGAL SERVICESLiving Willwith Health Care Power of Attorney
1. If I am unable to give directions about the use of life-sustaining
treatment, I want my family and any physician to honor this directive as the
final assertion of my legal right to refuse medical treatment.
2. I direct any physician to withhold or withdraw life-sustaining treatment
and to let me die if at any time I should either
A. have, in the written opinion of my attending physician, an
incurable injury, disease, or illness, causing an irreversible
terminal condition that will cause death within a reasonable
period of time, and if the use of life-sustaining treatment
would serve only to artificially prolong the process of dying,
B. be diagnosed in writing by two physicians, one of whom is
my attending physician and both of whom have personally
examined me, to be in a permanent unconscious condition.
3. I do not want either cardiopulmonary resuscitation (manual or mechanical efforts to restore heartbeat or breathing after they have stopped) or
assisted ventilation (use of a respirator to help keep a person breathing)
under the circumstances described in 2(A) or (B) above.
4. I do / I do not [circle one and cross out the other] want tube feeding
(use of a tube through the nose or abdomen for feeding a person who can’t
take food by mouth) under the circumstances described in 2(A) or (B)
5. I do / I do not [circle one and cross out the other] want artificial
hydration (giving liquids by tube or intravenously to a person who can’t
drink) under the circumstances described in 2(A) or (B) above unless it is
necessary for my comfort.Health Care Power of Attorney
6. I give a durable power of attorney to ____________________ to make
decisions for me, consistent with my living will, about medical treatment,
including the withholding or withdrawal of medical treatment, in the event
that my treating physician determines I have lost the mental capacity to
make such decisions for myself.
Date: ____________________
Printed name:_________________________________________________
street address city state
Statement of Witnesses
The maker of this living will (the “declarer”) signed it in my presence. He
or she has been personally known to me and I believe him or her to be
capable of making health care decisions, to understand this living will, and
to have signed it voluntarily. I am not related by blood or marriage to the
declarer, and I am not now entitled to receive any portion of the declarer’s
estate, either by will or by operation of law, or as a result of any claim
against the declarer. I am not the declarer’s attending physician or an
employee of that physician or of a health facility in which the declarer is a
Date: ____________________
Witness: ____________________________________________________
Witness: ____________________________________________________
[See Revised Code of Washington 70.122.030] [CLS 9/02]