District of Columbia Code Division I. Government of District. § 7-622 Declaration--Execution;  form.

(a) Any persons 18 years of age or older may execute a declaration directing the withholding or withdrawal of life-sustaining procedures from themselves should they be in a terminal condition.  The declaration made pursuant to this subchapter shall be:

(1) In writing;

(2) Signed by the person making the declaration or by another person in the declarant's presence at the declarant's express direction;

(3) Dated;  and

(4) Signed in the presence of 2 or more witnesses at least 18 years of age. In addition, a witness shall not be:

(A) The person who signed the declaration on behalf of and at the direction of the declarant;

(B) Related to the declarant by blood, marriage, or domestic partnership;

(C) Entitled to any portion of the estate of the declarant according to the laws of intestate succession of the District of Columbia or under any will of the declarant or codicil thereto;

(D) Directly financially responsible for declarant's medical care;  or

(E) The attending physician, an employee of the attending physician, or an employee of the health facility in which the declarant is a patient.

(b) It shall be the responsibility of the declarant to provide for notification to his or her attending physician of the existence of the declaration.  An attending physician, when presented with the declaration, shall make the declaration or a copy of the declaration a part of the declarant's medical records.

(c) The declaration shall be substantially in the following form, but in addition may include other specific directions not inconsistent with other provisions of this subchapter.  Should any of the other specific directions be held to be invalid, such invalidity shall not affect other directions of the declaration which can be given effect without the invalid direction, and to this end the directions in the declaration are severable.

Declaration

Declaration made this ․․․ day of ․․․․․․․․․․ (month, year).

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

If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by 2 physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that my death will occur whether or not life-sustaining procedures are utilized and where the application of life-sustaining procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfort care or to alleviate pain.

In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences from such refusal.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

Signed ․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․

Address ․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․

I believe the declarant to be of sound mind.  I did not sign the declarant's signature above for or at the direction of the declarant.  I am at least 18 years of age and am not related to the declarant by blood, marriage, or domestic partnership, entitled to any portion of the estate of the declarant according to the laws of intestate succession of the District of Columbia or under any will of the declarant or codicil thereto, or directly financially responsible for declarant's medical care.  I am not the declarant's attending physician, an employee of the attending physician, or an employee of the health facility in which the declarant is a patient.

Witness ․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․

Witness ․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․․


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