Medical law

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Lewis, M. A., & Tamparo, C. D. (20 12). Medical law, ethics, and bioethics for the health professions. Philadelphia: F. A. DaYis.



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Sample Documents for Choices About Health Care, Life, and Death


Available at http:/ patient_resources/ advance-directives-qa.cfm




254 Appendix 2 Sample Documents for Choices About Health Care, Life, and Death


Notice to Person Executing This Document

This is an important legal document. Before executing this document you should know these facts:

• This document gives the person you designate as your Health Care Agent the power to make MOST health care decisions for you if you lose the capability to make informed health care decisions for yourself. This power is effective only when you lose the capacity to make informed health care decisions for yourself. As long as you have the capacity to make informed health care decisions for yourself, you retain the right to make all medical and other health care decisions.

• You may include specific limitations in this document on the authority of the Health Care Agent to make health care decisions for you.

• Subject to any specific limitations you include in this document, if you do lose the capacity to make an informed decision on a health care matter, the Health Care Agent GENERALLY will be authorized by this document to make health care decisions for you to the same extent as you could make those decisions yourself, if you had the capacity to do so. The authority of the Health Care Agent to make health care decisions for you GENERALLY will incl ude the authority to give informed consent, to refuse to give informed consent , or to withdraw informed consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition . You can limit that right in this document if you choose.

• When exercising his or her authority to make health care decisions for you when deciding on your behalf, the Health Care Agent will have to act consistent with your wishes, or if they are unknown, in your best interest. You may make yo ur wishes known to the Health Care Agent by including them in this document or by making them known in another manner.

• When acting under this document the Health Care Agent GENERALLY will have the same rights that you have to receive information about proposed health care, to review health care records, and to consent to the disclosure of health care records.

1. Creation of Durable Power of Attorney for Health Care I intend to create a power of attorney (Health Care Agent) by appointing the person or persons designated herein to make health care decisions for me to the same extent that I could make such decisions for myself if I was capable of doing so, as recognized by RCW 11.94.01 0. This designation becomes effecti ve when I cannot make health care decisions for myself as determined by my attending physician or designee, such as if I am unconscious, or if I am otherwise temporarily or permanently incapable of making health care decisions. The Health Care Agent’s power shall cease if and when I regain my capacity to make health care decisions.

2. Designation of Health Care Agent and Alternate Agents If my attending physician or his or her designee determines that I am not capable of giving informed consent to health care, I , designate and appoint:

Name Address _ _________ _____ _ _ City State _ Zip Phone _ _ _____ _

as my attorney-in-fact (Health Care Agent) by granting him or her the Durable Power of Attorney for Health Care recognized in RCW 11.94.010 and authorize her or him to consult with my physicians about the possibility of my regaining the capacity to make treatment decisions and to accept, plan, stop, and refuse treatment on my behalf with the treating physicians and health personnel.

In the event that is unable or un willing to serve, I grant these powers to

Name Address ____ ____ ____ ___ _ _ City State _ Zip Phone _______ _

In the event that both and _ _______ ______ _ are unable or unwill ing to serve, I grant these powers to

Name Address _ _______ ________ _ City State _ Zip Phone ________ _

Your name _____________ ______________ ______________ __ _



Appendix 2 Sample Documents for Choices About Health Care, Life, and Death


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 w ill” I may have executed or elsewhere, and to receive and consent to the release of medical information. 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 ______________ _

(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 vol untary act for the uses and purposes mentioned in the instrument.

DATED this ___ _ _ ___ _ day of _____ _____ —— (year)

NOTARY PUBLIC in and for the State of Washington,

residing at————— —

My commission expires————-

NOTE: Washington state does not require this directive to be notarized or witnessed. Since some states do require it to be notarized; you may want to do so in the event you travel out-of-state.




256 Appendix 2 Sample Documents for Choices About Health Care, life, and Death


Directive made this day of ___________ , ____ __ _ (year)

___ ________________ _____ .being of sound mind, willfully, and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare that:

(A) If at any time I should have an incurable and irreversible condition certified to be a terminal condition by my attending physician, and where the application of life-sustaining treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally. I understand “terminal condition” means an incurable and irreversible condition caused by injury, disease, or illness that would, within reasonable medical judgment, cause death within a reasonable period of time in accordance with accepted medical standards.

(B) If I should be in an irreversible coma or persistent vegetative state or other permanent unconscious condition as certified by two physicians, and from which those physicians believe that I have no reasonable probability of recovery, I direct that life-sustaining treatment be withheld or withdrawn.

(C) If I am diagnosed to be in a terminal or permanent unconscious condition, [Choose one] I want do not want artificially administered nutrition and hydration to be withdrawn or withheld the same as other forms of life sustaining treatment. I understand artificially administered nutrition and hydration is a form of life-sustaining treatment in certain circumstances. I request all health care providers who care for me to honor this directive.

(D) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family, physicians, and other health care providers as the final exp ression of my fundamental right to refuse medical or surgical treatment, and also honored by any person appointed to make these decisions for me, whether by durable power of attorney or otherwise. I accept the consequences of such refusal.

(E) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy.

(F) I understand the full import of this directive and I am emotionally and mentally competent to make th is directive. I also understand that I may amend or revoke this directive at any time.

(G) I make the following additional directions regarding my care:

Signed _____________ _

The declarer has been personally known to me and I believe him or her to be of sound mind. In addition , I am not the attending ph ys ician , an employee of the attending physic ian or health care facility in which the declarer is a patient, or any person who has a c laim against any portion of the estate of the declarer upon the declarer’s decease at the time of the execution of the directive.


Witness ___ ______________ _



Appendix 2 Sample Documents for Choices About Health Care, Life, and Death

What To Do With These Forms

The attached Health Care Directive and Durable Power of Attorney for Health Care forms are all legal documents once they are completely filled out and signed with the appropriate signatures. Signed copies of the completed directives should be included in your medical record, given to any person to whom you give your durable power of attorney-including any alternate people yo u may have named-and to yo ur personal attorney. Originals should be kept by someone you trust and who can obtain them in an emergency.

Washington ‘s Online Living Will Registry

Washington residents can now register their advance planning documents with the Department of Health (DOH) on the online Living Will Registry. The Registry allows physicians or other health care providers to quickly access a patient’s documents via a secure website.

Registration is free and easy; fill out a registration form available at and then mail or fax it and your documents to the DOH. Those who register wi ll rece ive a wallet card and a sticker to place on their driver’s license. For more information, go to the Washington State Living Will Registry website at www.doh , or call the DOH ‘s Consumer Hot-line toll free, 1-800-525-0127.

For Further Information

These forms have been provided as a public service by the Washington State Medical Association. You are encouraged to discuss the directives with yo ur physician. Any legal questions you may have about the use and effect of these directives may be answered by an attorney.




258 Appendix 2 Sample Documents for Choices About Health Care, life, and Death



I, , of , give my organs, tissues, or parts as directed below. This Anatomical Gift will take effect upon my death.

I give: (initial one of the three options)

__ any needed organs, tissues , or parts.

___ any needed organs, tissues, or parts except:

___ the following organs, tissues, or parts only:

I give my organs, tissues, or parts indicated above to be used for: (in itial one of the two options)

_ __ any purpose authorized by law.

_ _ the following purposes onl y: (initial all that appl y)

___ transplantation


_ _ therapy


Limitations or special wishes, if an y:

If an y provision in this document is held to be in valid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision , and to this end the directions in this document are severable.

Date Signed ______ ____________ _

Donor _ ____________ __________ _

Signature _______ ___ __________ _

Donor’s Date of Birth

I witnessed that this document was signed in my presence by the Donor. I am signing in the presence of and at the direction of the Donor and in the presence of the other witness.



Witness – ———– ———-




Appendix 2 Sample Documents for Choices About Health Care, Life, and Death


Available at http:/ j forms/ donorcard.pdf

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r – – – – – – – – FOLD HER E – – – – –

UNIFORM DONOR CARD Signed by the donor and the follow ing t w o witnesses in the presence of each other

Signature of Donor Date of Birth

City and State Date Signed

Witness Witness

This a legal document under the Uniform Anatomical Gift Act or simi lar laws. For further information, contact the New England Organ Bank 1 800 446- NEOB or the Center for Donation and Tran splant 1 800 803-6667.


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