Page by page guide to Washington D.C.'s  Advance Health Care Directive

Advance Health Care Directive

You can download and print this form to fill out with a pen, or save it to your computer and type into it.

Download the District of Columbia Advance Health Care Directive now.

How to Share your Advance Health Care Directive with KP

Keep the original.

• Drop off a copy of your completed AHCD at the Medical Records Department of your Kaiser Permanente Medical Office Building.

Introduction (page 1)

1-A

Learn more about our approach to Life Care Planning

1-B

Please remember to write these items on every page:

• Your name.
• Your medical record number, which is found on your blue Kaiser insurance card.

Part 1: My Health Care Agent (page 2)

2-A

What are the qualities you should look for in agent? Learn how to choose an agent.

2-B

Learn more about what is an agent and their responsibilities.

2-C

Some people don’t have anyone in mind to be their agent. Learn about Life Care Planning without an agent.

2-D

An alternate agent would be needed if your primary agent is not available. Learn more about agents.

Part 1: My Health Care Agent (page 3)

3-A

Video: What I might consider when choosing my agent.

3-B

This space may be used for any instructions related to agents and their powers. If you have a family member who has beliefs about these topics that are significantly different from yours, you may decide to exclude this person from being involved in decision-making, even informally.

Part 1: My values (page 4)

4-A

In a serious medical situation, where the outcome is uncertain, your agent may look to this section for guidance. You’ll be doing your agent a favor by providing rich detail here.

4-B

For further guidance, read your values are at the center of your life care plan.

4-C

Consider some situations where values matter.

Part 3: My Health Care Instructions (page 5)

5-A

Should you ever be in a similar situation, it would be valuable for your agent to know your opinions about life sustaining treatment.

5-B

Video: Get more details about this brain injury scenario.

5-C

Video: Learn more accepting life sustaining treatments for a specific time period, in this scenario.

Part 3: My Health Care Instructions (page 6)

6-A

CPR can save lives, but it’s not as effective most people think. Read a discussion about CPR.

Part 4: My hopes and wishes (page 7)

7-A

Sometimes, our values inform not only what we want, but of what we don’t want. If you have some thoughts about how you would ideally like to die, please add them here.

7-B

If you are part of a faith community, please add in details of how we may contact them.

7-C

Be aware that if you’re interested in whole body donation, this is typically arranged well in advance and requires forms and documentation.

7-D

If you’re interested in organ donation, please be sure your agent is aware of this. Your agent would be responsible for arranging this at the time of death.

Part 5: Making this document legally valid (page 8)

8-A

Learn more about making this document legally valid.

Part 5: Making this document legally valid (page 9)

9-A

Learn more about making this document legally valid.

9-B

Please note that your appointed health-care agent may not serve as a witness. In addition, remember that your witnesses must both be adults.

9-C

At least one of your witnesses must be not related to you by blood, marriage or adoption, and also must be not entitled to the estate by a will.

Part 5: Making this document legally valid (page 10)

10-A

District of Columbia Declaration, to be signed by member

10-B

Member signs here

10-C

Your two witnesses sign here

Part 6: Next steps (page 11)

11-A

Learn more about sharing your values with your agent

11-B

If you have a scheduled appointment, you may hand deliver a copy to your doctor or you may hand-deliver a copy to your doctor, or you may visit Membership Services

11-C

If you’d like to let your doctor know you’ve completed your Advance Health Care Directive, and who you’ve chosen as your agent, you may send a secure message on kp.org

11-D

These are the people who require a copy of this document. Read more: Who needs to know about your Life Care Plan?