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
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.
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
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
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.