District of Columbia Medical Power of Attorney
This Medical Power of Attorney is designed to comply with the District of Columbia Health-Care Decisions Act. It allows you to appoint someone you trust to make health care decisions on your behalf if, and only if, you become unable to make them for yourself.
Please fill in the blanks with the required information:
I, _____________ (full legal name), residing at _________________ (address), appoint ________________ (name of the agent) of ________________ (agent's address), as my attorney-in-fact ("Agent") to make any and all health care decisions for me, except to the extent that I state otherwise.
This document gives your Agent the powers to make health care decisions for you. This includes the power to consent, refuse, or withdraw consent to any type of medical treatment, service, or procedure. It even covers the decision to provide, withhold, or withdraw artificial nutrition and hydration, and all other forms of health care to keep you alive.
Specific Instructions:
- Limitations on the agent's authority (if any): ________________________
- Preferences concerning types of treatment or care (if any): ________________________
- Directions concerning life-sustaining treatment (if any): ________________________
- Other wishes or instructions (if any): ________________________
By signing this document, you revoke any prior Medical Power of Attorney that you have made.
Your Agent will begin making decisions for you when your doctor certifies that you are unable to make health care decisions for yourself.
The authority of the Agent is subject to any limitations or conditions you set forth below, and to the District of Columbia laws, especially the provisions of the District of Columbia Health-Care Decisions Act that protect your rights.
Your Medical Power of Attorney needs to be signed and dated by you and two adult witnesses. The witnesses cannot be the person you have named as your Agent or alternate Agent, nor can they be your health care provider or an employee of your health care provider.
Signatures:
_____________________ (your signature)
Date: _______________
_____________________ (witness 1 signature)
Date: _______________
_____________________ (witness 2 signature)
Date: _______________
Agent's Acceptance:
I, ________________ (name of the agent), accept this appointment and agree to serve as an agent to make health care decisions for ________________ (your full legal name). I understand that this role comes with a duty to act in accordance with the wishes of the individual I represent, to the best of my knowledge and belief.
_____________________ (agent's signature)
Date: _______________