Fill - Free fillable Alaska Advance Health Care Directive (State of Alaska) PDF form

Alaska Advance Health Care

Directive

This booklet contains the Alaska statutory form for an

Advance Health Care Directive. Alaska Legal Services

Corporation (ALSC) provides this as a service to you and

does not take responsibility for how you fill it out. The law

allows you to prepare this form on your own. This booklet

contains general information to assist you. However, if you

have questions, please contact an attorney or

other knowledgeable source. The Alaska Bar Association’s

Lawyer Referral Service can provide you with a list of

private attorneys (272-0352 or 1-800-770-9999 outside

Anchorage). If you cannot afford an attorney or if you are 60

years or older, ALSC may be able to assist you.

Anchorage 272-9431 or (888) 478-2572; Bethel 543-2237 or

(800) 478-2230; Dillingham 842-1452 or (888) 383-2448;

Fairbanks 452-5181 or (800) 478-5401; Juneau 586-6425 or

(800) 789-6426; Kenai 395-0352 or (855)-395-0352; Ketchikan

225-6420 or (877) 525-6420; Kotzebue 442-7737 or (877)

622-9797; Nome 443-2230 or (888) 495-6663; Palmer

(746-4636) or (855) 996-4636; or Utqiagvik (Barrow) (855-8998)

or (855) 755-8998.

This booklet is provided by the Alaska Legal Services Corporation, a statewide

private nonprofit organization. Nothing contained in this publication is to be

considered as the rendering of legal advice for specific cases and readers are

responsible for obtaining such advice from an attorney.

Funding for this brochure came from the State of Alaska, Department of Health

and Social Services, Division of Senior and Disabilities Services.

For information regarding many other legal topics, see www.alaskalawhelp.org

Printed January 2017

ADVANCE HEALTH CARE DIRECTIVE

Alaska Statutes 13.52

Introductio

You have t

he 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;

programs of medication;

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

hydration and all other forms of health care; and

Advance Health Care Directive page 2 of 13

(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.

ter 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 t

he 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 partic

ipate in treatment decisions by means of a rational thought process.

Advance Health Care Directive page 3 of 13

PART 1

DURABLE POWER OF ATTORNEY FOR

HEALTH CARE DECISIONS

(1) DES

IGNATION 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)

_________________________________________________________

(telephone contact)

DESIGNATION OF FIRST ALTERNATE (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)

_________________________________

________________________

(telephone contact)

DESIGNATION OF SECOND ALTERNATE (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)

_________________________________________________________

(telephone contact)

Advance Health Care Directive page 4 of 13

(2) AGE

NT'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;

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) WHE

N 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.

I mark this box [ ], my agent's authority to make health care decisions

for me takes effect immediately.

(4) AGE

NT'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

Advance Health Care Directive page 5 of 13

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) NOMI

NATION OF GUARDIAN. If a guardian 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

NSTRUCTIONS FOR HEALTH CARE

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.

(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 co

mfort 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

Advance Health Care Directive page 6 of 13

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: ____________________

________________

________________________

__________________________________________

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:

__________________

_____________________________________________

Advance Health Care Directive page 7 of 13

(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

ANATO

MICAL GIFT AT DEATH

(Optional)

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,

[

] (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.

Advance Health Care Directive page 8 of 13

PART 4

MENTAL HEALTH TREATMENT

(optional)

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.

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) PS

YCHOTROPIC 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) ELE

CTROCONVULSIVE 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) ADM

ISSION 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:

Advance Health Care Directive page 9 of 13

________ 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 WIS

HES OR INSTRUCTIONS

_________________________________________________________

_________

________________________________________________

_________________________________________________________

Condition

s or limitations: _____________________________________________

_________________________________________________________________.

PART 5

PRIMAR

Y PHYSICIAN

(Optional)

(12) I d

esignate 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)

Advance Health Care Directive page 10 of 13

Advance Health Care Directive page 11 of 13

(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)

BIRTHDATE _______________

_________________________________________________________

(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

Witnesses Who are NOT RELATED to the Principal or

Who DO NOT BENEFIT Under the Terms of the Principal’s

Will

I swear und

er 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)

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; (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)

Advance Health Care Directive page 12 of 13

ALTERNATIVE NO. 2

State of

Alaska )

________________ Judicial District )

On this __

__ day of ___________________, 20____, before me 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.

Notar

y Seal

___________________________

(signature of notary public)

Advance Health Care Directive page 13 of 13

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