Durable Power of Attorney for Health Care - Virginia - Edit, Fill, Sign Online

ADVANCE DIRECTIVE

Your Durable Power of Attorney for Health Care, Living Will

and Other Wishes

This document has been prepared and distributed as an

informational service of the District of Columbia Hospital Association.

INSTRUCTIONS AND DEFINITIONS

Introduction

:

This form is a combined Durable Power of Attorney for Health Care and Living Will for use in

the District of Columbia, Maryland and Virginia. With this form, you can:

 Appoint someone to make health care decisions for you if you are unable to make

those decisions for yourself; and/or

 Indicate what health care treatments you do or do not want if you are unable to

make your wishes known.

Directions:

 Read each section carefully.

 Talk to the person you plan to appoint to make sure that he/she understands your

wishes, and is willing to take the responsibility to follow your wishes.

 Place the initials of your name in the blanks before those choices you want to

make.

 Fill in only those choices that you want under Parts 1, 2 and 3. Your advance

directive should be valid for whatever parts you fill in, as long as it is prop erly

signed.

 Add any special instructions in the blank spaces provided. You can write

additional comments on a separate sheet of paper. If you add pages, you should

indicate on the form that there are additional pages to your advance directive.

 Sign the form and have it witnessed.

 Give a copy of your advance directive to your doctor, nurse, the person you

appoint to make your health care decisions for you, your family, your clergy,

your attorney, and anyone else who might be involved in your care.

 Understand that you may change or cancel this document at any time.

Words You Need to Know:

Advance Directive: A written document that tells what a person wants or does not want if in the

future he/she cannot make his/her wishes known about health care treatment.

Artificial Nutrition and Hydration: When food and water are given to a person through a tube.

Autopsy: An examination done on a dead body to find the cause of death.

Comfort Care: Care that helps to keep a person comfortable. Pain relief, bathing, turning,

keeping a person's lips moist are types of comfort care.

CPR (Cardiopulmonary Resuscitation): An attempt to try and restart a person's breathing or

heartbeat. CPR may include pushing on the chest, putting a tube down the throat, and/or other

treatment.

Durable Power of Attorney for Health Care: An advance directive that appoints someone to

make health care decisions for a person if he/she cannot make or communicate his/her own

decisions. That person may be a family member or a friend, but does not need to be a lawyer.

The person appointed must follow your wishes if they are known. If they are not known, the

person must make decisions based on what he/she thinks you would want.

End-Stage Condition: A chronic, irreversible condition caused by injury or illness that has

caused serious, permanent damage to the body. A person in an end-stage condition requires

others to provide most of his/her care.

Life-Sustaining Treatment: Any health care treatment that is used to keep a person from dying.

A breathing machine, CPR, dialysis, artificial nutrition and hydration are examples of life-

sustaining treatment.

Living Will: An advance directive that tells what health care treatment a person does or does not

want if he/she is not able to make his/her wishes known.

Organ and Tissue Donation: When a person permits his/her organs (such as eyes or kidneys)

or other parts of the body (such as skin) to be removed after death to be transplanted for use by

another person.

Permanent Coma: When a person is unconscious with no hope of regaining consciousness even

with medical care. In a coma, a person is not awake or aware of surroundings.

Persistent Vegetative State: When a person has brain damage that makes him/her unaware of

pain or surroundings and has no hope of improvement, even with maximum medical treatment.

The eyes may be open and the body may move.

Terminal Condition: An advanced, irreversible condition caused by injury or illness that has no

cure and from which doctors expect the person to die, even with maximum medical treatment.

Lifesustaining treatments will not improve the person's condition and will only prolong a

person's dying.

District of Columbia, Maryland and Virginia

ADVANCE DIRECTIVE

My Durable Power of Attorney for Health Care, Living Will and Other Wishes

I, ____________________, write this document as a directive regarding my health care.

(Put the initials of your name by the choices you want)

PART 1: MY DURABLE POWER OF ATTORNEY FOR HEALTH CARE

As long as I can make my wishes known, my doctors will talk to me and I will make my own

health care decisions.

_____ If there ever comes a time when I cannot make health care decisions about myself, I

appoint this adult person to make decisions for me:

____________________________________________________________________________

name home phone work phone

____________________________________________________________________________

address

___________________________________

email

_____ If the person above cannot or will not make decisions for me, I appoint a second person:

____________________________________________________________________________

name home phone work phone

____________________________________________________________________________

address

____________________________________

email

_____ I understand that if I do not appoint a Durable Power of Attorney for Health Care,

someone may be designated to make my health care decisions by law or by a court.

I want the person I have appointed, my doctors, my family and others to be guided by my

wishes described on the following pages.

PART 2: MY LIVING WILL

A. Use this page to help the person you have named in Part 1 make decisions for you,

according to how you feel about certain medical conditions. This information may also be

helpful to your doctor and others who will care for you.

In general, these should be the goals of my care if I have an end-stage or terminal condition or

am in persistent vegetative state, with no hope of improvement:

____________________________________________________________________________