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.
