Learn more about advance care planning below. For help with advance
care planning, please contact Honoring Choices PNW at
firstname.lastname@example.org. Any legal questions you may have about the use and effect of an
advance directive may be answered by an attorney.
What is advance care planning?
Advance care planning is thinking about what health care you might
want in the future. This type of planning includes talking about,
writing down, and sharing what is important to you. This helps others
make health care decisions for you if you cannot make your own
decisions. In this situation, a person close to you would need to make
decisions for you. This person is called a health care agent, also
known as an attorney-in-fact, surrogate, or legal medical decision
maker. It is important that you prepare your health care agent by
sharing how you would want them to make health care decisions for you.
What is an advance directive?
An advance directive is a voluntary, legal way to write down your
advance care planning decisions. You should share your advance
directive with people who matter to you—like your health care agent
and loved ones—and your health care providers, clinic, and hospital.
An advance directive should be updated regularly. All adults 18 and
older can complete an advance directive.
There are two types of advance directives in Washington state: 1) a
durable power of attorney for health care and 2) a health care
The advance directive in this booklet is a durable power of attorney
for health care (DPOA-HC). The DPOA-HC is based on Washington state
law (chapter 11.125 RCW). This legal form allows you to name your
health care agent to make health care decisions for you if you cannot
make your own decisions. The Honoring Choices PNW advance directive
also helps you prepare your health care agent by sharing your goals,
values, and preferences. Research shows that the best way to ensure
your wishes are followed is to name and prepare a health care agent.
The advance directive in this booklet is not a health care directive
(chapter 70.122 RCW). Health care directives are also known as living
wills. You may consider also completing a health care directive, which
is a directive to withdraw or withhold life-sustaining treatment in
specific situations under Washington state law. For more information
on a health care directive, visit:
or talk with your health care provider.
What makes a good health care agent?
Your health care agent SHOULD:
Understand what a health care agent does and be willing to fill this
Share your goals, values, and preferences with your health care
providers, and describe what “living well” or a “good day” means to
Carry out your decisions, even if they do not agree with your
- Be able to make decisions in difficult or stressful times.
Your health care agent CANNOT be:
- Under 18 years old.
Your physician or your physician’s employee (unless they are your
spouse, state registered domestic partner, parent, adult child, or
An owner, administrator, or employee of a health care facility or
long-term care facility where you receive care or live (unless they
are your spouse, state registered domestic partner, parent, adult
child, or adult sibling).
What can a health care agent do?
If you cannot make your own health care decisions, your health care
agent will be asked to make health care decisions for you. Your health
care agent can use the information you share in this advance directive
and in conversations to guide your care.
Consistent with state law and using their understanding of your goals,
values, and preferences, your health care agent can:
Decide on treatments and surgeries, including whether to use
cardiopulmonary resuscitation (CPR), a breathing machine, a feeding
tube, and other treatments.
Decide whether to end life-support treatment and focus on comfort
Review and release medical records for your care and/or apply for
health care insurance benefits on your behalf.
Choose the health care providers and organizations to provide your
What is CPR?
Cardiopulmonary resuscitation or CPR is a procedure used when your
heart and breathing stop. CPR works best if your body is healthy and
CPR is started right away after your heart stops. CPR is less likely
to be successful if you are weak, elderly, or have a serious illness.
If you survive, you might need a ventilator (breathing machine)
because of weakened lungs. It is important to talk to your health care
providers about whether CPR would meet your goals.
Standard care in Washington state is to provide CPR to people if their
heart and breathing stop. Sharing your CPR wishes on this DPOA-HC form
can guide your “code status” if you are hospitalized. Code status
means the type of emergent treatment a person would or would not
receive in the hospital if their heart or breathing stop.
Some people who choose not to receive CPR in a hospital also do not
want CPR in other settings. In this situation you should ask your
health care provider about completing a Portable Orders for
Life-Sustaining Treatment (POLST). POLST is a medical order that
communicates health care decisions to emergency responders and other
What is life support?
Life-support (also known as life-sustaining) treatments are medical
treatments that keep you alive by supporting or replacing important
body functions. These treatments do not cure medical conditions. They
keep you alive until you either get better or you are taken off life
support and are allowed to die naturally. Some examples of
life-support treatments are CPR, breathing machines, feeding tubes,
blood transfusions, and kidney dialysis. It is important to know that
easing pain and providing comfort are part of routine care and not
considered life-support treatments.
What happens if I do not name a health care agent?
If you cannot make your own health care decisions and a health care
agent is not named, your health care providers will follow Washington
state law to determine who can act as your medical decision maker.
This means they will ask family members or friends to make health care
decisions for you. If family or friends cannot be identified from the
list below, health care providers may ask a court to appoint a
guardian to make health care decisions on your behalf.
Health care providers will contact people in the following order until
they can identify a medical decision maker for you (chapter 7.70.065
- A guardian appointed by a court (if applicable)
- Named health care agent(s)*
- Spouse or registered domestic partner
- Adult children*
- Adult siblings*
- Adult grandchildren who are familiar with the patient*
- Adult nieces and nephews who are familiar with the patient*
- Adult aunts and uncles who are familiar with the patient*
- A close adult friend who meets certain criteria
* For any group that has more than one person, everyone in the
group must agree to the care.
What are some situations that may apply?
Naming your spouse as your health care agent
If you choose your spouse or registered domestic partner as your
health care agent, they will stop being your named health care agent
if either of you file for dissolution, annulment, or legal separation
(chapter 11.125.100 RCW). However, the Honoring Choices PNW advance
directive allows you to choose to have them continue as your health
care agent, even after divorce.
If this situation applies to you, initial next to this statement on
Page 1 of the Honoring Choices PNW advance directive: “If I name my
spouse or registered domestic partner as my health care agent and we
later file for a dissolution, annulment, or legal separation; I want
them to continue as my health care agent.”
Not naming a health care agent
Although a primary goal of the Honoring Choices PNW advance directive
is to name a health care agent, you have the option not to name one.
If a health care agent is not named, health care providers will follow
Washington state law to determine who can act as your medical decision
maker (chapter 7.70.065 RCW).
If you complete the other sections of the Honoring Choices PNW advance
directive, it will be considered a personal values statement and not
an advance directive. A personal values statement is a summary of your
goals, values, and preferences. This information can guide your
medical decision maker on how to make decisions on your behalf.
If this situation applies to you, initial next to this statement on
Page 1 of the Honoring Choices PNW advance directive: “I am not naming
a health care agent. By sharing my goals and values in this form, it
will be considered a personal values statement and not an advance
In this situation, you may also consider completing a health care
directive, also known as a living will, which is a directive to
withdraw or withhold life-sustaining treatment in specific situations
under Washington state law. For more information, visit
or talk with your health care provider.
What should I do with this advance directive?
Once you complete this advance directive, you should talk about your
wishes and share copies with the people who matter to you—like your
health care agent and loved ones—and your health care providers,
clinic, and hospital. If it applies, consider sharing copies with your
nursing home or assisted living facility too. It is important that
everyone has a copy.
What if I change my mind?
If you change your mind about the decisions in your advance directive,
tell everyone who has a copy, including your health care agent, loved
ones, health care providers, clinic, and hospital. You can revoke or
void your advance directive at any time. You will need to tell your
health care provider that you want to revoke it either by writing them
a letter (make sure to sign and date it) or by verbally telling them.
It is important to complete a new advance directive. Be sure to give
copies of the new advance directive to the people who matter to
you—like your health care agent and loved ones—and your health care
providers, clinic, and hospital.
What about organ, tissue, and eye donation?
If you want to be a donor, please tell your health care agent, family,
and health care providers. You can also record your organ and tissue
donation wishes at
Who decides how to handle my body after I die?
The Honoring Choices PNW advance directive does not direct the
disposal of your remains. Consider completing a form that specifically
provides instructions on how to handle your body after you die
consistent with state law (chapter 68.50.160 RCW).
Who can I contact if I need help with advance care planning?
Honoring Choices PNW is here to help you. For local resources, visit:
www.honoringchoicespnw.org/locations. Please contact us at
Are advance directives legal?
Yes. There are federal and state laws that govern the use of advance
directives. All 50 states and the District of Columbia have laws
recognizing the use of advance directives. If you travel, you may want
to take copies of your documents with you, as other states may honor
Will advance directives be recognized in emergencies?
No. During most emergencies, there is not enough time for emergency
service personnel to consult the patient's advance directive. Once the
patient is under the direct care of a physician, there will be time
for the advance directive to be evaluated and/or the health care agent
to be consulted. For individuals with serious health conditions, there
is a form in Washington state that can help represent your wishes in
emergency medical situations called the Portable Orders for
Life-Sustaining Treatment form. For more information on POLST, please
ask your physician, or visit our