Washington Durable Power of Attorney for Health Care

3. General Statement of Authority Granted.
My Health Care Agent is specifically authorized to give informed consent for health care treatment when I am not capable
of doing so. This includes but is not limited to consent to initiate, continue, discontinue, or forgo medical care and
treatment including artificially supplied nutrition and hydration, following and interpreting my instructions for the
provision, withholding, or withdrawing of life-sustaining treatment, which are contained in any Health Care Directive or
other form of “living will” I may have executed or elsewhere, and to receive and consent to the release of medical informa-
tion. When the Health Care Agent does not have any stated desires or instructions from me to follow, he or she shall act
in my best interest in making health care decisions.
The above authorization to make health care decisions does not include the following absent a court order:
(1) Therapy or other procedure given for the purpose of inducing convulsion;
(2) Surgery solely for the purpose of psychosurgery;
(3) Commitment to or placement in a treatment facility for the mentally ill, except pursuant to the provisions of
Chapter 71.05 RCW;
(4) Sterilization.
I hereby revoke any prior grants of durable power of attorney for health care.
4. Special Provisions
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
DATED this _______________________ day of _______________________ , ______________ .
GRANTOR __________________________________________
STATE OF WASHINGTON )
(COUNTY OF ________________________ )
I certify that I know or have satisfactory evidence that the GRANTOR, ___________________________________________________________
signed this instrument and acknowledged it to be his or her free and voluntary act for the uses and purposes mentioned in the instrument.
DATED this _______________________ day of _______________________ , ______________ .
_____________________________________________________________________
NOTARY PUBLIC in and for the State of Washington,
residing at_____________________________________________________________
My commission expires __________________________________________________
(Year)
(Year)
)ss.
Your name (print)______________________________________
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