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Alaska Statutes.

Title 13. Decedents' Estates, Guardianships, Transfers, and Trusts.

Chapter 52. Health Care Decisions Act

Section 300. Optional Form.

AS 13.52.300. Optional Form.

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

   (a) consent or refuse consent to any care, treatment, service, or

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;&

   (d) direct the provision, withholding, or withdrawal of artificial

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

   (1) to assimilate relevant facts and to appreciate and understand

your situation with regard to those facts; and

   (2) to participate in treatment decisions by means of a rational

thought process.

PART 1

DURABLE POWER OF ATTORNEY FOR

HEALTH CARE DECISIONS

   (1) DESIGNATION OF AGENT.

I designate the following individual as my 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)

   (2) AGENT'S AUTHORITY. 
My agent is authorized and directed to follow

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

     (A) the effect of the treatment on your physical, emotional, and	

cognitive functions

     (B) the degree of physical pain or discomfort caused to you by the 

treatment or the withholding or withdrawal of the treatment;

     (C) the degree to which your medical condition, the treatment, or	

the withholding or withdrawal of treatment, results in a severe and    

continuing impairment;

     (D) the effect of the treatment on your life expectancy;

     (E) your prognosis for recovery, with and without the treatment;	

     (F) the risks, side effects, and benefits of the treatment or the	

withholding of treatment; and

     (G) your religious beliefs and basic values, to the extent that	

these may assist in determining benefits and burdens.



   (3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE.

Except in the case of 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.



   (4) AGENT'S OBLIGATION.
 
My agent shall make health care decisions 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.



   (5) NOMINATION OF GUARDIAN. 

If a guardian of my person needs to be 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, advanced 

practice registered nurses, physician assistants, and other health 

care providers. You may obtain a copy of the protocol from the Alaska

Department of Health. A 'do not resuscitate order' means a directive 

from a licensed physician, advanced practice registered nurse, physician 

assistant that emergency cardiopulmonary resuscitation should not be 

administered to you.



   (6) END-OF-LIFE DECISIONS. 
Except to the extent prohibited by law, I 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) [ ] 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) [ ] 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)

       [ ] (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

       [ ] (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;

[ ] 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),

[ ] I wish to receive artificial nutrition and hydration indefinitely; 

[ ] I wish to receive artificial nutrition and hydration indefinitely, 

unless it clearly increases my suffering and is no longer in my best   

interest;

[ ] I wish to receive artificial nutrition and hydration on a limited  

trial basis to see if I can improve;

[ ] In accordance with my choices in (6)(B) above, I do not wish to    

receive artificial nutrition and hydration.

[ ] Other instructions: _____________________________________________  

_____________________________________________________________________
 
     (D) Relief from Pain.

[ ] I direct that adequate treatment be provided at all times for the  

sole purpose of the alleviation of pain or discomfort; or

[ ] 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
ANATOMICAL GIFT AT DEATH 
(OPTIONAL)

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)
     (A) [ ] I give any needed organs, tissues, or other
body parts, OR 

     (B) [ ] I give the following organs, tissues, or

other body parts only _________________________________________________________

     (C) [ ] My gift is for the following purposes

(mark any of the following you want):

       [ ] (i) transplant

       [ ] (ii) therapy;

       [ ] (iii) research;

       [ ] (iv) education.

     (D) [ ] 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.


   (9) PSYCHOTROPIC MEDICATIONS.
If I do not have the capacity to give 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: ___________________________________________ 

______________________________________________________________________. 



   (10) ELECTROCONVULSIVE TREATMENT.
If I do not have the capacity to 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: ___________________________________________ 

______________________________________________________________________. 



   (11) ADMISSION TO AND RETENTION IN FACILITY.
If I do not have the 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)


   (12) I designate the following physician as my primary physician:



____________________________________________________________________

 (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)


   (13) EFFECT OF COPY.

A copy of this form has the same effect as the original.


   (14) SIGNATURES.

Sign and date the form here:



______________________________________________________________________

 (date) (sign your name)



______________________________________________________________________

 (print your name)




______________________________________________________________________

 (address) (city) (state) (zip code)



   (15) WITNESSES.
This advance care health directive will not be valid for making health care 

decisions unless it is
     (A) signed by two qualified adult witnesses who are
personally 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

   (1) a health care provider employed at the health care institution
or health care facility where the principal is receiving health care;
   (2) an employee of the health care provider providing health care to
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;
   (5) related to the principal by blood, marriage, or adoption; or
   (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

   (1) a health care provider employed at the health care institution
or health care facility where the principal is receiving health care; 

   (2) an employee of the health care provider who is providing health
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)