Default Medical Decision Maker in Washington: Who Decides If You Don't Have a Directive

When someone is rushed to the hospital unconscious, with no advance directive on file, the family doesn't get to vote on who speaks for them. Washington law has already decided — and the answer surprises most families.

Under RCW 7.70.065, healthcare providers must follow a strict, non-negotiable priority hierarchy to identify a surrogate decision-maker. They can't skip ahead, they can't let the family sort it out informally, and they can't proceed without consent from the appropriate priority class.

Washington's 10-Level Surrogate Hierarchy

Healthcare providers must make documented, reasonable efforts to locate someone in a higher priority class before descending to a lower one. A lower-class surrogate has no authority if any competent member of a higher class has actively refused to authorize the proposed treatment.

The Unanimity Rule: Where Families Get Stuck

Classes 4, 6, 7, 8, and 9 all require unanimous agreement among all reasonably available members. This is where the system breaks down in practice.

Say a patient has three adult children. Two want to authorize surgery; one doesn't. Under Washington law, the hospital cannot proceed — not because the dissenting child has veto power in the traditional sense, but because the statute requires unanimity within the class before the surrogate authority is valid.

The dissenting child doesn't need to provide a reason. They don't need a medical opinion. They just need to refuse to consent, and the decision stalls.

When unanimity can't be reached, the family's options are limited:

• Attempt mediation (no statutory framework for this in the medical context)
• Petition the court for a guardian with healthcare decision-making authority (slow, expensive, adversarial)
• Risk litigation under Washington's Trust and Estate Dispute Resolution Act (TEDRA)

None of these happen quickly. Meanwhile, the patient is in a hospital bed without a decision.

The Community Property Misconception

Washington is a community property state, and many married couples assume this means the surviving or competent spouse automatically makes all decisions. It doesn't.

Community property rules govern asset ownership — who owns what during marriage and what happens to property after death. They have nothing to do with medical decision-making authority.

Under the surrogate hierarchy, a spouse sits at Priority 3 — which means they do get priority over adult children and other family members. But if there's a court-appointed guardian (Priority 1) or a designated agent in a DPOA-HC (Priority 2), the spouse's authority is subordinate. And if the spouse is also incapacitated, or is in the middle of a divorce, they're disqualified entirely — pushing authority down to the adult children and their unanimity requirement.

The Close Friend Provision

Priority 10 allows a "close friend" to serve as surrogate, but the requirements are substantial:

• The friend must demonstrate special care and concern for the patient
• They must be familiar with the patient's personal values
• They must be reasonably available
• They must sign a dated, written declaration under penalty of perjury confirming their relationship, regular contact, and lack of awareness of any willing surrogate in a higher class

The declaration is subject to conflict-of-interest exclusions: the friend cannot be the attending physician, an employee of that physician, or an owner/administrator/employee of the healthcare facility (unless related by blood or marriage).

And the declaration expires after six months. If the patient's incapacity extends beyond that, the friend must execute a new declaration.

How a DPOA-HC Bypasses All of This

A Durable Power of Attorney for Health Care puts a single named person at Priority 2 — above the spouse, above the children, above the unanimity traps. Your designated agent has clear authority to make decisions, and the hospital doesn't need to work down the hierarchy or wait for family consensus.

The DPOA-HC doesn't eliminate family involvement. Your agent can still consult with family members. But when it comes time to sign a consent form or refuse a treatment, one person has unambiguous legal authority to act. No unanimity requirement. No waiting for an estranged sibling to return a phone call.

Washington's advance directive kit includes both the DPOA-HC and the Health Care Directive, with a witness checklist and instructions for making sure the documents are on file where they'll be found in an emergency.

See more Washington guides →