1
ALABAMA
Advance Directive
Planning for Important Health Care Decisions
CaringI
nfo
1731 King St., Suite 100,
Alexandria,
VA 22314
www.caringinfo.org
800/658-8898
CARINGINFO
CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO),
is a national consumer engagement initiative to improve care at the end of life.
It’s About How You LIVE
It’s
About
How You LIVE is a national community engagement campaign encouraging
individuals to make informed decisions about end-of-life care and services. The
campaign encourages people to:
Learn about options for end-of-life services and care
Implement plans to ensure wishes are honored
Voice decisions to family, friends and health care providers
Engage in personal or community efforts to improve end-of-life care
Note: The following is not a substitute for legal advice. While CaringInfo updates the
following information and form to keep them up-to-date, changes in the underlying law
can affect how the form will operate in the event you lose the ability to make decisions
for yourself. If you have any questions about how the form will help ensure your wishes
are carried out, or if your wishes do not seem to fit with the form, you may wish to talk
to your health care provider or an attorney with experience in drafting advance
directives. If you have other questions regarding these documents, we
recommend c
ontacting
your state attorney general's office.
Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Revised
2019. Reproduction and distribution by an organization or organized group without the written
permission of the National Hospice and Palliative Care Organization is expressly forbidden.
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Using these Materials
BEFORE YOU BEGIN
1. Check to be sure that you have the materials for each state in which you may
receive health care.
2. These materials include:
Instructions for preparing your advance directive, please read all of the
instructions.
Your state-specific advance directive forms, which are the pages with
the gray instruction bar on the left side.
ACTION STEPS
1. You may want to photocopy or print a second set of these forms before you start
so you will have a clean copy if you need to start over.
2. When you begin to fill out the forms, refer to the gray instruction bars — they
will guide you through the process.
3. Talk with your family, friends, and physicians about your advance directive. Be
sure the person you appoint to make decisions on your behalf understands your
wishes.
4. Once the form is completed and signed, photocopy the form and give it to the
person you have appointed to make decisions on your behalf, your family,
friends, health care providers and/or faith leaders so that the form is available in
the event of an emergency.
5. Alabama does not maintain an Advance Directive Registry, but you may file your
advance directive with the office of the probate judge in the county in which you
reside. Although no one is required to search for your advance directive, filing
your advance directive may help your health care provider and loved ones be
able to find a copy of your directive in the event you are unable to provide one.
6. You may also want to save a copy of your form in an online personal health
records application, program, or service that allows you to share your medical
documents with your physicians, family, and others who you want to take an
active role in your advance care planning.
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Introduction to Your Alabama Advance Directive for Health Care
This packet contains an
Alabama Advance Directive
for
Health
Care which
protects your right to refuse medical treatment you do not want or to request
treatment you do want in the event you lose the ability to make decisions
yourself. This document is in substantially the same form as set forth in the
Alabama Natural Death Act.
Section 1 of this document is your state’s Living Will. It lets you discuss your
wishes about medical care in the event that you are permanently unconscious or
develop a terminal condition and can no longer make your own medical
decisions.
Section 2 of this document permits the appointment of a
Health
Care Proxy. This
section lets you name someone to make decisions about your medical care,
including decisions about life-sustaining treatment, if you can no longer speak for
yourself.
Section 3 explains some of the limitations of this document and allows you to list
the people you want your doctor to talk to if the time comes for you to stop
receiving life-sustaining treatment.
Section 4 of this document is an optional organ donation form that will allow you
to make or refuse to make a donation of your organs and tissues.
Section 5 is for your signature. Your advance directive must be signed in the
presence of two witnesses.
Section 6 is a proxy signature form. Alabama law requires that your proxy
accept his or her role in writing. If your proxy is unavailable to sign this
document immediately, a copy of the entire form should be mailed to the proxy,
who should then return a signed copy of the proxy signature page.
Your Alabama advance directive for health care goes into effect when your doctor
determines that you are no longer able to understand, appreciate and direct your
medical treatment, and your doctor and one other doctor experienced in making
the diagnosis determine that you are permanently unconscious or terminally ill
and document such diagnosis in your medical record.
This form does not expressly address mental illness. If you would like to make
advance care plans involving mental illness, you should talk to your physician and
an attorney about a durable power of attorney.
Note:
This
document
will be
legally binding
only if the
person completing
the
document
is a
competent
adult, 19 years of age or older.
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Instructions for Completing Your Alabama Advance Directive for
Health Care
How do I make my
Alabam
a
Advance Direct
ive for
H
ealt
h Care legal?
The law requires that you sign your document, or direct another to sign it, in the
presence of two witnesses, who must be at least 19 years of age.
Your witnesses cannot be:
your appointed health care proxy,
related to you by blood, adoption or marriage,
entitled to any portion of your estate upon your death, either through
your will or under the laws of interstate succession,
directly financially responsible for your medical care, or
the person who signed your document on your behalf.
These witnesses must also sign the document to show that they personally know
you, believe you to be of sound mind, and that they do not fall into any of the
categories of people who cannot be witnesses.
Note: You do not need to
notarize
your
Alabama Advance
Directive.
Can I add personal instructions to my
Liv
in
g
W
ill?
One of the strongest reasons for naming a proxy is to have someone who can
respond flexibly as your medical situation changes and deal with situations that
you did not foresee. If you add instructions to this document it may help your
proxy carry out your wishes, but be careful that you do not unintentionally
restrict your proxy’s power to act in your best interest. In any event, be sure to
talk with your proxy about your future medical care and describe what you
consider to be an acceptable “quality of life.”
Whom should I appoint as my proxy?
Your proxy is the person you appoint to make decisions about your medical care
if you become unable to make those decisions yourself. Your proxy may be a
family member or a close friend whom you trust to make serious decisions. The
person you name as your proxy should clearly understand your wishes and be
willing to accept the responsibility of making medical decisions for you.
You can appoint a second person as your alternate proxy. The alternate will step
in if the first person you name as a proxy is unable, unwilling, or unavailable to
act for you.
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Instructions for Completing Your Alabama Advance Directive for
Health Care (continued)
What if I change my mind?
You may revoke your Advance Directive for Health Care at any time by:
obliterating, burning, tearing or otherwise destroying or defacing the
document,
executing, or directing another person to execute, a signed and dated
written revocation (formal statement that you have changed your mind),
or
orally expressing your intent to revoke the Advance Directive for Health
Care in the presence of a witness, 19 years of age or older, who must
sign and date a written confirmation that you made an oral revocation.
An oral revocation becomes effective once the signed and dated
confirmation is given to your doctor or health care provider, who will
then make it a part of your medical record.
What other important facts should I know?
The directions of a pregnant patient’s Alabama Advance Directive for Health
Care authorizing the providing, withdrawal or withholding of life-sustaining
treatments and artificially provided nutrition and hydration will not be honored
due to restrictions in the state law.
Your proxy, if you appoint one, does not have authority to authorize
psychosurgery, sterilization, or abortion—unless it is necessary to save your
life—or to have you involuntarily hospitalized or treated for mental illness.
INSTRUCTIONS
PRINT YOUR
NAME
PLACE YOUR
INITIALS BY EITHER
YES OR NO
PLA
CE YOUR
INITIALS BY
EITHER YES OR NO
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 1 OF 8
This form may be used in the State of Alabama to make your wishes known
about what medical treatment or other care you would or would not want if you
become too sick to speak for yourself. You are not required to have an advance
directive. If you do have an advance directive, be sure that your doctor, family,
and friends know you have one and know where it is located.
Section 1. LIVING WILL
I, , being of sound mind and at least 19 years
old, would like to make the following wishes known. I direct that my family, my
doctors and health care workers, and all others follow the directions I am writing
down. I know that at any time I can change my mind about these directions by
tearing up this form and writing a new one. I can also do away with these
directions by tearing them up and by telling someone at least 19 years of age of
my wishes and asking him or her to write them down.
I understand that these directions will only be used if I am not able to speak for
myself.
IF I BECOME TERMINALLY ILL OR INJURED:
Terminally ill or injured is when my doctor and another doctor decide that I have
a condition that cannot be cured and where death will result in the near future
without the use of artificial life sustaining procedures.
Life-Sustaining Treatment:
Life-Sustaining Treatment includes drugs, machines, or medical procedures that
would keep me alive but would not cure me. I know that even if I choose not to
have life-sustaining treatment, I will still get medicines and treatments that ease
my pain and keep me comfortable.
Place your initials by either Yes or No:
I want to have life-sustaining treatment if I am terminally ill or injured.
Yes No
Artificially provided food and hydration (Food and water through a tube or an IV)
I understand that if I am terminally ill or injured I may need to be given food
and water through a tube or an IV to keep me alive if I can no longer chew or
swallow on my own or with someone helping me.
Place your initials by either Yes or No:
I want to have food and water provided through a tube or an IV if I am
terminally ill or injured. Yes No
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ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 2 OF 8
IF I BECOME PERMANENTLY UNCONSCIOUS:
Permanent unconsciousness is when my doctor and another doctor agree that
within a reasonable degree of medical certainty I can no longer think, feel
anything, knowingly move, or be aware of being alive. They believe this
condition will last indefinitely without hope for improvement and have watched
me long enough to make that decision. I understand that at least one of these
doctors must be qualified to make such a diagnosis.
PLACE YOUR
INITIALS BY
EITHER YES OR NO
Life-Sustaining Treatment:
Life-sustaining treatment includes drugs, machines, or other medical procedures
that would keep me alive but would not cure me. I know that even if I choose
not to have life-sustaining treatment, I will still get medicine and treatments that
ease my pain and keep me comfortable.
Place your initials by either Yes or No:
I want to have life-sustaining treatment if I am permanently unconscious.
Yes No
Artificially Provided Food and Hydration:
Artificially provided food and hydration (Food and water through a tube or an IV)
I understand that if I become permanently unconscious, I may need to be given
food and water through a tube or an IV to keep me alive if I can no longer chew
or swallow on my own or with someone helping me.
PLA
CE YOUR
INITIALS BY
EITHER YES OR NO
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
Place your initials by either Yes or No:
I want to have food and water provided through a tube or an IV if I am
permanently unconscious. Yes No
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ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 3 OF 8
ADD OTHER
INSTRUCTIONS, IF
ANY, REGARDING
YOUR ADVANCE
CARE PLANS
OTHER DIRECTIONS:
Please list any other things that you want done or not done:
In addition to the directions I have listed on this form, I also direct the following:
THESE
INSTRUCTIONS
CAN
FURTHER
ADDRESS
YOUR
HEALTH
CARE
PLANS,
SUCH AS
YOUR WISHES
REGARDING
HOSPICE
TREATMENT, BUT
CAN ALSO ADDRESS
OTHER ADVANCE
PLANNING ISSUES,
SUCH AS YOUR
BURIAL
WISHES
ATTACH
ADDITIONAL PAGES
IF NEEDED
IF YOU DO NOT
HAVE OTHER
If you do not have other directions, place your initials here:
DIRECTIONS, PLACE
No, I do not have other directions.
YOUR INITIALS
HERE
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
8
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ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 4 OF 8
Section 2. HEALTH CARE PROXY
This form can be used in the State of Alabama to name a person you would like
to make medical or other decisions for you if you become too sick to speak for
yourself. This person is called a health care proxy. You do not have to name a
health care proxy. The directions in this form will be followed even if you do not
name a health care proxy.
PLA
CE YOUR
INITIALS BY ONLY
ONE ANSWER
PRINT THE NAME,
RELATIONSHIP AND
ADDRESS OF YOUR
PROXY
This Section 2 creates a power of attorney that shall become effective upon the
disability, incompetence, or incapacity of the principal, and is in substantially the
same form as set forth in the Alabama Natural Death Act.
Place your initials by only one answer:
I do not want to name a health care proxy.
(If you check this answer go to section 3.)
I do want the person listed below to be my health care proxy.
I have talked with this person about my wishes.
First choice for proxy:
Relationship to me:
Address:
City: State: Zip:
Day-time phone number:
PRINT THE
NAME,
RELATIONSHIP
AND ADDRESS
OF YOUR
ALTERNATE
PROXY
Night-time phone number:
If this person is not able, not willing, or not available to be my health care proxy,
this is my next choice:
Second choice for proxy:
Relationship to me:
Address:
© 2005 Nati
onal
Hospice and
Palliative Care
Organization
2019 Revised.
City: State: Zip:
Day-time phone number:
Night-time phone number:
10
ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 5 OF 8
Instructions for Proxy
Place your initials by either yes or no:
INITIAL
YES OR NO
PLACE YOUR
I want my health care proxy to make decisions about whether to give me food
and water through a tube or an IV.
Yes No
Place your initials by only one of the following:
INITIALS BEFORE I want my health care proxy to follow only the directions as listed on this
ONE OF THE THREE
OPTIONS
form.
I want my health care proxy to follow my directions as listed on this form
and to make any decisions about things I have not covered in the form.
I want my health care proxy to make the final decision, even though it
could mean doing something different from what I have listed on this form.
Section 3.
The things listed on this form are what I want.
I understand the following:
If my doctor or hospital does not want to follow the directions I have listed, they
must see that I get to a doctor or hospital that will follow my directions.
If I am pregnant, or if I become pregnant, the choices I have made on this form
will not be followed until after the birth of the baby.
LIST TH
E PEOPLE
YOU WOULD WANT
YOUR DOCTOR TO
TALK WITH
© 2005 Nati
onal
Hospice and
Palliative Care
Organization
2019 Revised.
If the time comes for me to stop receiving life-sustaining treatment or food and
water through a tube or an IV, I direct that my doctor talk about the good and
bad points of doing this, along with my wishes, with my health care proxy, if I
have one, and with the following people:
11
ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 6 OF 8
Section 4.
ORGAN DONATION
(OPTIONAL)
CHECK TH
E
OPTION THAT
REFLECTS YOUR
WISHES
ORGAN DONATION (OPTIONAL)
In the space below you may make a gift yourself or state that you do not want
to make a gift. The donation elections you make below survive your
death.
Initial the line next to the statement below that best reflects your wishes. You
do not have to initial any of the statements. If you do not initial any of the
statements, your agent and your family will have the authority to make
a gift of all or part of your body under Alabama law.
I do not want to make an organ or tissue donation and I do not want my
agent or family to do so.
I have already signed a written agreement or donor card regarding organ
and tissue donation with the following individual or institution:
Name of individual / institution:
Pursuant to Alabama law, I hereby give, effective on my death: (Select
one)
CHECK TH
E
OPTION THAT
REFLECTS YOUR
WISHES. ADD
PERSONAL
INSTRUCTIONS, IF
ANY
© 2005 Nati
onal
Hospice and
Palliative Care
Organization
2019 Revised.
Any needed organ or parts.
The following part or organs listed below:
For the following purpose: (Select one)
Any legally authorized purpose.
Transplant or therapeutic purposes only.
12
ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 7 OF 8
Section 5. Execution
PRINT YOUR NAME,
THE MONTH, DAY
AND YEAR OF
YOUR BIRTH
SIGN AND DATE
YOUR DOCUMENT
My signature
Your Name
The Month, Day, and Year of your birth:
Your signature:
Date signed:
WITNESSING
PROCEDURE
WITNESSES
MUST SIGN
THEIR NAMES
WITNESS #1
WITNESS #2
Witnesses (need two witnesses to sign)
I am witnessing this form because I believe this person to be of sound mind. I
did not sign the person’s signature and I am not the health care proxy. I am not
related to the person by blood, adoption, or marriage and not entitled to any
part of his or her estate. I am at least 19 years of age and am not directly
responsible for paying for his or her medical care.
Name of first witness:
Signature: Date:
Name of second witness:
Signature: Date:
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
13
ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 8 OF 8
Section 6. Signature of Proxy
THE PROXY AND
ANY ALTERNATE
PROXY MUST
PRINT THEIR
NAMES AND SIGN
AND DATE THE
DOCUMENT
IF EITHER PROXY
IS UNAVAILABLE
TO SIGN THIS
DOCUMENT
IMMEDIATELY, A
COPY OF THE
ENTIRE FORM
SHOULD BE
MAILED TO THE
PROXY, WHO
SHOULD THEN
RETURN A SIGNED
COPY OF THE
PROXY SIGNATURE
PAGE.
© 2005 National
Hospice and
Palliative Care
Organization
2019 Revised.
I, , am willing to serve as the health
care
proxy for .
Signature:
Date:
Signature of second choice for proxy:
I, _________________________________, am willing to serve as the
health care
proxy for if the first choice cannot serve.
Signature:
Date:
Courtesy
of
Carin
gIn
fo
1731 King St., Suite 100,
Alexandria,
VA
22314
www.caringinfo.org, 800
/
658-
8898
14
You Have Filled Out Your Alabama Advance Directive for Health Care, Now
What?
1. Your
Alabama Advance Directive
for
Health
Care is an important legal document. Keep
the original signed document in a secure but accessible place. Do not put the original
document in a safe deposit box or any other security box that would keep others from
having access to it.
2. Alabama law requires that your proxy accept his or her role in writing. If your proxy is
unavailable to sign this document immediately, a copy of the entire form should be
mailed to the proxy, who should then return a signed copy of the proxy signature page.
3. Give photocopies of the signed original to your agent and alternate agent, doctor(s),
family, close friends, clergy and anyone else who might become involved in your health
care. If you enter a nursing home or hospital, have photocopies of your document
placed in your medical records.
4. Be sure to talk to your agent(s), doctor(s), clergy, family and friends about your wishes
concerning medical treatment. Discuss your wishes with them often, particularly if your
medical condition changes.
5. Alabama does not maintain an Advance Directive Registry, but you may file your
advance directive with the office of the probate judge in the county in which you reside.
Although no one is required to search for your advance directive, filing your advance
directive may help your health care provider and loved ones find a copy of your
directive in the event you are unable to provide one.
6. You may also want to save a copy of your form in an online personal health records
application, program, or service that allows you to share your medical documents with
your physicians, family, and others who you want to take an active role in your advance
care planning.
7. If you want to make changes to your documents after they have been signed and
witnessed, you must complete a new document.
8. Remember, you can always revoke your Alabama document.
9. Be aware that your Alabama document will not be effective in the event of a medical
emergency. Ambulance and hospital emergency department personnel are required to
provide cardiopulmonary resuscitation (CPR) unless they are given a separate directive
that states otherwise. These directives called “prehospital medical care directives” or
“do not resuscitate orders” are designed for people whose poor health gives them little
chance of benefiting from CPR. These directives instruct ambulance and hospital
emergency personnel not to attempt CPR if your heart or breathing should stop. We
suggest you speak to your physician for more information. CaringInfo does not
distribute these forms.
Congratulations!
You’ve downloaded your free, state specific advance directive.
You are taking important steps to make sure your wishes are known. Please consider helping us
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