Fill - Free fillable ALABAMA Advance Directive Planning for Important Health Care PDF form

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.

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.

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.

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.

Instructions for Completing Your Alabama Advance Directive for

Health Care

How do I make my

Alabam

Advance Direct

ive for

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

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.

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),

•

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

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

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

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

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

Hospice and

Palliative Care

Organization

2019 Revised.

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:

onal

Hospice and

Palliative Care

Organization

2019 Revised.

City: State: Zip:

Day-time phone number:

Night-time phone number:

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

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:

ALABAMA ADVANCE DIRECTIVE FOR HEALTH CARE PAGE 6 OF 8

Section 4.

ORGAN DONATION

(OPTIONAL)

CHECK TH

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

OPTION THAT

REFLECTS YOUR

WISHES. ADD

PERSONAL

INSTRUCTIONS, IF

ANY

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.

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:

Hospice and

Palliative Care

Organization

2019 Revised.

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.

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

Carin

gIn

1731 King St., Suite 100,

Alexandria,

22314

www.caringinfo.org, 800

658-

8898

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.

OR donate online today: www.NationalHospiceFoundation.org/donate

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

keep this resource free.

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resources, tools, and information to educate and empower individuals to access advance care

planning, caregiving, hospice and grief services.

Please show your support for our mission and consider making a tax-deductible gift

to the National Hospice Foundation today.

Since 1992, the National Hospice Foundation has been dedicated to creating FREE resources for

individuals and families facing a life-limiting illness, raising awareness for the need for hospice

and palliative care, and providing ongoing professional education and skills development to

hospice and palliative care professionals across the nation. To learn more, please visit

www.NationalHospiceFoundation.org

You may wonder if a gift of $35, $50 or $100 to the National Hospice Foundation would make a

difference, but it is only because of the generosity of others like you that these FREE resources

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Return to:

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PO Box 824401

Philadelphia, PA 19182-4401

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