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The following sample form may be used to create an advance health care directive. The other sections of this chapter govern the effect of this or any other writing used to create an advance health care directive. This form may be duplicated. This form may be modified to suit the needs of the person, or a different form that complies with this chapter may be used, including the mandatory witnessing requirements:
ADVANCE HEALTH CARE DIRECTIVE
Explanation
You have the right to give instructions about your own health care to
the extent allowed by law. You also have the right to name someone else
to make health care decisions for you to the extent allowed by law.
This form lets you do either or both of these things. It also lets you
express your wishes regarding the designation of your health care
provider. If you use this form, you may complete or modify all or any
part of it. You are free to use a different form if the form complies
with the requirements of AS 13.52.
Part 1 of this form is a durable power of attorney for health care. A
'durable power of attorney for health care' means the designation of an
agent to make health care decisions for you. Part 1 lets you name
another individual as an agent to make health care decisions for you if
you do not have the capacity to make your own decisions or if you want
someone else to make those decisions for you now even though you still
have the capacity to make those decisions. You may name an alternate
agent to act for you if your first choice is not willing, able, or
reasonably available to make decisions for you. Unless related to you,
your agent may not be an owner, operator, or employee of a health care
institution where you are receiving care.
Unless the form you sign limits the authority of your agent, your agent
may make all health care decisions for you that you could legally make
for yourself. This form has a place for you to limit the authority of
your agent. You do not have to limit the authority of your agent if you
wish to rely on your agent for all health care decisions that may have
to be made. If you choose not to limit the authority of your agent,
your agent will have the right, to the extent allowed by law, to
procedure to maintain, diagnose, or otherwise affect a physical or
mental condition, including the administration or discontinuation of
psychotropic medication;
(b) select or discharge health care providers and institutions;
(c) approve or disapprove proposed diagnostic tests, surgical
procedures, and programs of medication;
nutrition and hydration and all other forms of health care; and
(e) make an anatomical gift following your death.
Part 2 of this form lets you give specific instructions for any aspect
of your health care to the extent allowed by law, except you may not
authorize mercy killing, assisted suicide, or euthanasia. Choices are
provided for you to express your wishes regarding the provision,
withholding, or withdrawal of treatment to keep you alive, including
the provision of artificial nutrition and hydration, as well as the
provision of pain relief medication. Space is provided for you to add
to the choices you have made or for you to write out any additional
wishes.
Part 3 of this form lets you express an intention to make an anatomical
gift following your death.
Part 4 of this form lets you make decisions in advance about certain
types of mental health treatment.
Part 5 of this form lets you designate a physician to have primary
responsibility for your health care.
After completing this form, sign and date the form at the end and have
the form witnessed by one of the two alternative methods listed below.
Give a copy of the signed and completed form to your physician, to any
other health care providers you may have, to any health care
institution at which you are receiving care, and to any health care
agents you have named. You should talk to the person you have named as
your agent to make sure that the person understands your wishes and is
willing to take the responsibility.
You have the right to revoke this advance health care directive or
replace this form at any time, except that you may not revoke this
declaration when you are determined not to be competent by a court, by
two physicians, at least one of whom shall be a psychiatrist, or by
both a physician and a professional mental health clinician. In this
advance health care directive, 'competent' means that you have the
capacity
your situation with regard to those facts; and
thought process.
PART 1
DURABLE POWER OF ATTORNEY FOR
HEALTH CARE DECISIONS
agent to make health care decisions for me:
______________________________________________________________________ (name of individual you choose as agent)
______________________________________________________________________ (address) (city) (state) (zip code)
______________________________________________________________________ (home telephone) (work telephone)
OPTIONAL: If I revoke my agent's authority or if my agent is not
willing, able, or reasonably available to make a health care decision
for me, I designate as my first alternate agent
_____________________________________________________________________ (name of individual you choose as first alternate agent)
_____________________________________________________________________ (address) (city) (state) (zip code)
_____________________________________________________________________ (home telephone) (work telephone)
OPTIONAL: If I revoke the authority of my agent and first alternate
agent or if neither is willing, able, or reasonably available to make a
health care decision for me, I designate as my second alternate agent
_____________________________________________________________________ (name of individual you choose as second alternate agent)
_____________________________________________________________________ (address) (city) (state) (zip code)
_____________________________________________________________________ (home telephone) (work telephone)
my individual instructions and my other wishes to the extent known to
the agent in making all health care decisions for me. If these are not
known, my agent is authorized to make these decisions in accordance
with my best interest, including decisions to provide, withhold, or
withdraw artificial hydration and nutrition and other forms of health
care to keep me alive, except as I state here:
_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ (Add additional sheets if needed.)
Under this authority, 'best interest' means that the benefits to you
resulting from a treatment outweigh the burdens to you resulting from
that treatment after assessing
cognitive functions;
treatment or the withholding or withdrawal of the treatment;
the withholding or withdrawal of treatment, results in a severe and
continuing impairment;
(D) the effect of the treatment on your life expectancy;
withholding of treatment; and
these may assist in determining benefits and burdens.
mental illness, my agent's authority becomes effective when my primary
physician determines that I am unable to make my own health care
decisions unless I mark the following box. In the case of mental
illness, unless I mark the following box, my agent's authority becomes
effective when a court determines I am unable to make my own decisions,
or, in an emergency, if my primary physician or another health care
provider determines I am unable to make my own decisions. If I mark
this box, my agent's authority to make health care decisions for me
takes effect immediately.
for me in accordance with this durable power of attorney for health
care, any instructions I give in Part 2 of this form, and my other
wishes to the extent known to my agent. To the extent my wishes are
unknown, my agent shall make health care decisions for me in accordance
with what my agent determines to be in my best interest. In determining
my best interest, my agent shall consider my personal values to the
extent known to my agent.
appointed for me by a court, I nominate the agent designated in this
form. If that agent is not willing, able, or reasonably available to
act as guardian, I nominate the alternate agents whom I have named
under (1) above, in the order designated.
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you are satisfied to allow your agent to determine what is best for
you in making health care decisions, you do not need to fill out this
part of the form. If you do fill out this part of the form, you may
strike any wording you do not want. There is a state protocol that
governs the use of do not resuscitate orders by physicians and other
health care providers. You may obtain a copy of the protocol from the
Alaska Department of Health and Social Services. A 'do not resuscitate
order' means a directive from a licensed physician that emergency
cardiopulmonary resuscitation should not be administered to you.
direct that my health care providers and others involved in my care
provide, withhold, or withdraw treatment in accordance with the choice
I have marked below: (Check only one box.)
(A) ‡ ñ Choice To Prolong Life
I want my life to be prolonged as long as possible within the limits of
generally accepted health care standards; OR
(B) ‡ ñ Choice Not To Prolong Life
I want comfort care only and I do not want my life to be prolonged with
medical treatment if, in the judgment of my physician, I have (check
all choices that represent your wishes)
‡ ñ (i) a condition of permanent unconsciousness: a condition that, to
a high degree of medical certainty, will last permanently without
improvement; in which, to a high degree of medical certainty, thought,
sensation, purposeful action, social interaction, and awareness of
myself and the environment are absent; and for which, to a high degree
of medical certainty, initiating or continuing life-sustaining
procedures for me, in light of my medical outcome, will provide only
minimal medical benefit for me; or
‡ ñ (ii) a terminal condition: an incurable or irreversible illness or
injury that without the administration of life-sustaining procedures
will result in my death in a short period of time, for which there is
no reasonable prospect of cure or recovery, that imposes severe pain
or otherwise imposes an inhumane burden on me, and for which, in light
of my medical condition, initiating or continuing life-sustaining
procedures will provide only minimal medical benefit;
‡ ñ Additional instructions: _________________________________________
__________________________________________________________________ (C) Artificial Nutrition and Hydration. If I am unable to safely
take nutrition, fluids, or nutrition and fluids (check your choices or
write your instructions),
‡ ñ I wish to receive artificial nutrition and hydration indefinitely;
‡ ñ I wish to receive artificial nutrition and hydration indefinitely,
unless it clearly increases my suffering and is no longer in my best
interest;
‡ ñ I wish to receive artificial nutrition and hydration on a limited
trial basis to see if I can improve;
‡ ñ In accordance with my choices in (6)(B) above, I do not wish to
receive artificial nutrition and hydration.
‡ ñ Other instructions: _____________________________________________
_____________________________________________________________________ (D) Relief from Pain.
‡ ñ I direct that adequate treatment be provided at all times for the
sole purpose of the alleviation of pain or discomfort; or
‡ ñ I give these instructions: ______________________________________
_____________________________________________________________________ (E) Should I become unconscious and I am pregnant, I direct that
_____________________________________________________________________ _____________________________________________________________________ (7) OTHER WISHES. (If you do not agree with any of the optional
choices above and wish to write your own, or if you wish to add to the
instructions you have given above, you may do so here.) I direct that
_____________________________________________________________________ _____________________________________________________________________ Conditions or limitations: __________________________________________
____________________________________________________________________.
(Add additional sheets if needed.)
PART 3
(OPTIONAL)
ANATOMICAL GIFT AT DEATH
If you are satisfied to allow your agent to determine whether to make
an anatomical gift at your death, you do not need to fill out this
part of the form.
(8) Upon my death: (mark applicable box)
only ________________________________________________________________
(C) ‡ ñ My gift is for the following purposes (mark any of the
following you want):
‡ ñ (i) transplant;
‡ ñ (ii) therapy;
‡ ñ (iii) research;
‡ ñ (iv) education.
(D) ‡ ñ I refuse to make an anatomical gift.
PART 4
MENTAL HEALTH TREATMENT
This part of the declaration allows you to make decisions in advance
about mental health treatment. The instructions that you include in
this declaration will be followed only if a court, two physicians that
include a psychiatrist, or a physician and a professional mental health
clinician believe that you are not competent and cannot make treatment
decisions. Otherwise, you will be considered to be competent and to
have the capacity to give or withhold consent for the treatments.
If you are satisfied to allow your agent to determine what is best for
you in making these mental health decisions, you do not need to fill
out this part of the form. If you do fill out this part of the form,
you may strike any wording you do not want.
or withhold informed consent for mental health treatment, my wishes
regarding psychotropic medications are as follows:
________ I consent to the administration of the following medications:
_____________________________________________________________ ________ I do not consent to the administration of the following
medications: _________________________________________________________
Conditions or limitations: ___________________________________________
_____________________________________________________________________.
give or withhold informed consent for mental health treatment, my
wishes regarding electroconvulsive treatment are as follows:
________ I consent to the administration of electroconvulsive
treatment.
________ I do not consent to the administration of electroconvulsive
treatment.
Conditions or limitations: ___________________________________________
_____________________________________________________________________.
capacity to give or withhold informed consent for mental health
treatment, my wishes regarding admission to and retention in a mental
health facility for mental health treatment are as follows:
________ I consent to being admitted to a mental health facility for
mental health treatment for up to ________ days. (The number of days
not to exceed 17.)
________ I do not consent to being admitted to a mental health facility
for mental health treatment.
Conditions or limitations: ___________________________________________
_____________________________________________________________________.
OTHER WISHES OR INSTRUCTIONS
______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Conditions or limitations: ___________________________________________
_____________________________________________________________________.
PART 5
PRIMARY PHYSICIAN
(OPTIONAL)
____________________________________________________________________ (name of physician)
____________________________________________________________________ (address) (city) (state) (zip code)
____________________________________________________________________ (telephone)
OPTIONAL: If the physician I have designated above is not willing,
able, or reasonably available to act as my primary physician, I
designate the following physician as my primary physician:
____________________________________________________________________ (name of physician)
____________________________________________________________________ (address) (city) (state) (zip code)
____________________________________________________________________ (telephone)
original.
(14) SIGNATURES. Sign and date the form here:
______________________________________________________________________ (date) (sign your name)
______________________________________________________________________ (print your name)
______________________________________________________________________ (address) (city) (state) (zip code)
for making health care decisions unless it is
known to you and who are present when you sign or acknowledge your
signature; the witnesses may not be a health care provider employed at
the health care institution or health care facility where you are
receiving health care, an employee of the health care provider who is
providing health care to you, an employee of the health care
institution or health care facility where you are receiving health
care, or the person appointed as your agent by this document; at least
one of the two witnesses may not be related to you by blood, marriage,
or adoption or entitled to a portion of your estate upon your death
under your will or codicil; or
(B) acknowledged before a notary public in the state.
ALTERNATIVE NO. 1
Witness Who is Not Related to or a Devisee of the Principal
I swear under penalty of perjury under AS 11.56.200 that the principal
is personally known to me, that the principal signed or acknowledged
this durable power of attorney for health care in my presence, that the
principal appears to be of sound mind and under no duress, fraud, or
undue influence, and that I am not
or health care facility where the principal is receiving health care;
the principal;
(3) an employee of the health care institution or health care
facility where the principal is receiving health care;
(4) the person appointed as agent by this document;
(6) entitled to a portion of the principal's estate upon the
principal's death under a will or codicil.
______________________________________________________________________ (date) (signature of witness)
______________________________________________________________________ (printed name of witness)
______________________________________________________________________ (address) (city) (state) (zip code)
Witness Who May be Related to or a Devisee of the Principal
I swear under penalty of perjury under AS 11.56.200 that the principal
is personally known to me, that the principal signed or acknowledged
this durable power of attorney for health care in my presence, that the
principal appears to be of sound mind and under no duress, fraud, or
undue influence, and that I am not
or health care facility where the principal is receiving health care;
care to the principal;
(3) an employee of the health care institution or health care
facility where the principal is receiving health care; or
(4) the person appointed as agent by this document.
_____________________________________________________________________ (date) (signature of witness)
_____________________________________________________________________ (printed name of witness)
_____________________________________________________________________ (address) (city) (state) (zip code)
ALTERNATIVE NO. 2
State of Alaska
________ Judicial District
On this ________ day of __________, in the year ________, before me,
_____________________________________ (insert name of notary public) appeared ________________________ , personally
known to me (or proved to me on the basis of satisfactory evidence) to
be the person whose name is subscribed to this instrument, and
acknowledged that the person executed it.
Notary Seal
____________________________ (signature of notary public)
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Last modified 9/3/2005