Washington Medical Power of Attorney Form

Through the fulfillment of this form, a resident of Washington will be able to grant someone with the legal power to decide on medical matters concerning her/him. Usually, this form is used by individuals expecting the loss of their cognitive abilities later in life.Download

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Durable Power of Attorney for Health Care 
I, __________________________________, domiciled in the State of Washington, designate 
_____________________________ as my attorney in fact, to act for me in making health care 
decisions if I become incapacitated. I hereby revoke all health care powers of attorney previously 
granted by me. 
1. Alternate Attorney in Fact. If for any reason ___________________________ fails or ceases to 
act, I designate _____________________________, then __________________________ as 
alternate attorneys in fact, to serve in the order named. An attorney in fact may resign by delivering 
written notice to that effect, in recordable form, to an alternate, successor, or co-attorney in fact. In 
this Power of Attorney, the "attorney in fact" means the then acting attorney in fact. 
2. Power to Make Health Care Decisions. My attorney in fact shall have the right to make decisions, 
and to give informed consent on my behalf, as to my health care. This authority shall include, but not 
be limited to, consent to the withholding or withdrawal of life-sustaining treatment, including*/but not 
including* artificially provided nutrition and hydration, if at any time (1) I should be diagnosed in 
writing by my attending physician to be in a terminal condition (an incurable and irreversible condition 
caused by injury, disease, or illness, that would within reasonable medical judgment cause death 
within a reasonable amount of time in accordance with accepted medical standards) or (2) in a 
permanent unconscious condition (an incurable and irreversible condition in which I am medically 
assessed within reasonable medical judgment as having no reasonable probability of recovery from an 
irreversible coma or persistent vegetative state) by two physicians; and where the application of life-
sustaining treatment would serve only to artificially prolong the process of dying. I give this authority 
with the intent that it be honored by my attorney-in-fact to permit me to die naturally. 
* (cross out one) 
3. Effectiveness. This Power of Attorney shall become effective upon my incapacity. Incapacity shall 
include the inability to make health care decisions effectively for reasons such as mental illness, 
mental deficiency, incompetency, physical illness or disability, chronic use of drugs or chronic 
intoxication. Incapacity may be determined (i) by court order or (ii) by a qualified regularly attending 
physician, whose affidavit in recordable form to that effect shall be conclusive of incapacity. An 
affidavit executed as described herein may be relied upon without inquiry by any person dealing with 
the attorney in fact. 
4. Duration. This Power of Attorney becomes effective as provided in Section 3 and shall remain in 
effect to the fullest extent permitted by Chapter 11.94 of the Revised Code of Washington, or until 
revoked or terminated as provided in Section 5 or 6. 
5. Revocation. This Power of Attorney may be revoked, suspended, or terminated by written notice 
from me to the designated attorney in fact and, if this power has been recorded, by recording the 
notice in the office where deeds are recorded for real estate located in ____________________ 
County, Washington. 
6. Termination. If appointed a guardian of my person may, with court approval, revoke, suspend, or 
terminate this Power of Attorney. 
7. Reliance. Any person dealing with the attorney in fact shall be entitled to rely upon this Power of 
Attorney so long as the person with whom the attorney in fact was dealing, at the time of any act 
taken pursuant to this Power of Attorney, had neither actual knowledge nor written notice of any 
revocation, suspension, or termination of this Power of Attorney. Any action so taken, unless 
otherwise invalid or unenforceable, shall be binding on my heirs, devisees, legatees, or personal 
representatives.

8. Indemnity. My estate shall hold harmless and indemnify the attorney in fact from all liability for acts 
or omissions done in good faith. 
9. Applicable Law. The internal law of the State of Washington shall govern this Power of Attorney. 
10. Execution. This Power of Attorney is signed in duplicate on the _________ day of  
___________________, to be effective as provided in Section 3. 
_____________________________________ 
Signed 
_____________________________________  
Witness 
____________________________________ 
Witness  
  
Notarization, If Needed: 
STATE OF WASHINGTON            ) 
                                         ) ss. 
COUNTY OF _____________     ) 
I certifiy that I know or have satisfactory evidence that ______________________ 
signed this instrument and acknowledged it to be his/her free and voluntary act for the uses and 
purposes mentioned in the instrument. 
Dated: _______________________. 
(Seal or stamp)                                                 ______________________________ 
Notary Public in and for the State of 
Washington, residing at ___________ 
My appointment expires ___________ 
(Although there is no statutory requirement for witnessing or notarization of this form of Durable 
Power, it is strongly recommended that there always be two witnesses and that these witnesses be 
persons qualified as witnesses to a Health Care Directive, so that the Durable Power will itself be valid 
as a Directive under the Natural Death Act in case the signer does not have a separate Directive. 
Further, if the form of Durable Power used is broader than this form and extends to the handling of 
the patient's property and business affairs in addition to health care, it should always be notarized, 
whether there are witnesses or not. Witnessing and/or notarization is also important as evidence to 
help confirm the patient's competence and help assure the patient's wishes are carried out should 
family members or other oppose on the grounds the patient did not understand what he or she was 
doing when signing the document.)