Sample HCD


1.   Directive to Physicians.   I, DAVID SMITH (“Declarant”), having the capacity to make health care decisions, 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:

This Directive is made this ______ day of ___________________, 2020.

a. If at any time I should be diagnosed in writing to be in a terminal condition by my attending physician, or in a permanent unconscious condition by two (2) physicians, and if 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treatment would serve only to artificially prolong the process of my dying, I direct that such treatment be withheld or withdrawn and that I be permitted to die naturally.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 that a “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, and where the application of life-sustaining treatment would serve only to prolong the process of dying. I further understand that a “permanent unconscious condition” means 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 a persistent vegetative state. I define “artificially provided nutrition and hydration” to mean those not given by mouth including those given by nasal-gastric or oral-gastric tube.

b. In the absence of my ability to give directions regarding the use of such life-sustaining treatment, it is my intention that my family and physicians shall honor this Directive as the final expression of my legal right to refuse medical or surgical treatment, and I accept the consequences of such refusal. If another person is appointed to make these decisions for me, whether through a Durable Power of Attorney or otherwise, I request that the person be guided by this Directive and any other clear expressions of my desires.

c. If I am diagnosed to be in a terminal condition or in a permanent unconscious condition:

[Initial Your Choice]

_____________ I DO want to have artificially provided nutrition.

_____________ I DO NOT want to have artificially provided nutrition.

_____________ I DO want to have artificially provided hydration.

_____________ I DO NOT want to have artificially provided hydration.

_____________ I DO want to have CPR performed on me.

_____________ I DO NOT want to have CPR performed on me.

_____________ I DO want to receive antibiotic therapy.

_____________ I DO NOT want to receive antibiotic therapy.

d. I understand the full import of this Directive, and I am emotionally and mentally capable to make the health care decisions contained in this Directive.

e. I understand that before I sign this Directive, I can add to or delete from or otherwise change the wording of this Directive and that I may add to or delete from this Directive at any time and that any changes shall be consistent with Washington State law or federal constitutional law to be legally valid.

f. It is my wish that every part of this Directive be fully implemented. If for any reason any part is held invalid, it is my wish that the remainder of my Directive be implemented.

2.  Supplement to Directive to Physicians.   Under the public policy declared in the Washington Natural Death Act (the “Act”) and the authority granted in the Act to include other specific directions in the Directive to Physicians set forth above, I declare and direct as follows:

a. I am of sound mind and willfully and voluntarily make this Supplement. I do not intend that these additional specific directions revoke or in any way impair the effectiveness of any provision of the above Directive to Physicians. I intend, however, that all provisions of the Act apply to this Supplement and to the persons, institutions, medical facilities and personnel as fully and in all respects as they would if this Supplement were expressly authorized by the Act. In the event of any conflict between the terms of my Directive to Physicians above and the following terms, the terms of my Directive to Physicians shall prevail.

b. I request care that gives me comfort and support, that facilitates my interactions with those around me, and that relieves my pain and suffering. In case of pain, I request that drugs be administered to relieve pain or anxiety, even if they may hasten the time of my death or modify my vital signs. I understand that extended use of pain medications can lead to physiologic tolerance and I may need increasing amounts of pain medications to relieve my pain. However, I forbid all those actions whose direct purpose is to terminate my life.

c. I request that I not be hospitalized or put in a convalescent or similar home as long as it is economically feasible and reasonable to maintain me in my personal residence.

d. In addition to the directions set forth in paragraphs 1.a and 1.c, above, if my physician does not determine that I am in a terminal or permanently unconscious condition, but does determine that severe and permanent mental and physical deterioration is present and there is no reasonable likelihood for recovery, I direct that the procedures specified in paragraphs 1.a and 1.c be withheld or withdrawn and that I be permitted to die naturally.

e. If I am critically ill and there is little chance of recovery, I feel that it is not necessary to employ extraordinary means to preserve my health or life. For me, extraordinary means are those that place a grave burden on my family or me. There must be due proportion between the benefit that is expected and the burden I bear to achieve it. The “burden” of treatment must not be greatly larger than the expected benefit. “Burden” can include pain, loss of human dignity, financial cost, and submission to onerous treatments that do not offer cure or relief from suffering. If I am critically ill and my chance of recovery is uncertain, I expect that a reasonable amount of time (one or two weeks or longer) be employed to determine if my health will improve.

f. I intend that my family, my physicians and their medical assistants, my clergy, my lawyer, and any medical facility and its personnel caring for me cooperate with me and with each other in carrying out my directions and in allowing me to die with dignity. I have executed the Directive to Physicians and this Supplement in part to relieve them all of any feelings of guilt or of responsibility for my death that they might otherwise have.

g. This Directive to Physicians and Supplement supersedes all prior “Living Wills” or similar instruments I may have signed, and I hereby revoke such prior instruments.

h. If any of my tissue or organs are sound and would be of value as transplants to other people, I freely give my permission for such donations. I understand that before any vital organ, tissue or eye may be removed for transplantation, I must be pronounced dead. I understand that my estate will not be charged for any costs associated with my decision to donate my organs, tissues or eyes or the actual disposition of my organs, tissues or eyes.

i. I desire to have my remains cremated.




Bellingham, Whatcom County, Washington


Each of the undersigned declares under penalty of perjury under the laws of Washington State, on this __________ day of ________________, 2020, at Bellingham, Washington, that the following is true and correct:

1.  DAVID SMITH, Declarant, has been personally known to me, and I believe Declarant to be capable of making health care decisions.

2.  I am not:

a. Related to Declarant by blood, marriage or adoption;

b. Entitled to any portion of Declarant’s estate upon Declarant’s death under any Will or Codicil of Declarant or by operation of law;

c. Declarant’s attending physician;

d. An employee of the attending physician or a health facility in which Declarant is a patient; or

e. Any person who has a claim against any portion of the estate of Declarant upon Declarant’s death.

3.  I believe Declarant to be of sound mind and that Declarant signed the foregoing Directive to Physicians and Supplement willfully and voluntarily.


Signature: _____________________

Print Name: ____________________

Signature: _____________________

Print Name: ____________________

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