Alaska Statutory Living Will

DECLARATION

If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.

I ( ___ ) do ( ___ ) do not desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary.

Notwithstanding the other provisions of this declaration, if I have donated an organ under this declaration or by another method, and if I am in a hospital when a do not resuscitate order is to be implemented for me, I do not want the do not resuscitate order to take effect until the donated organ can be evaluated to determine if the organ is suitable for donation.

OPTIONAL: In the event of my death, I donate the following part(s) of my body for the (medical) purposes identified in Alaska state law AS 13.50.020 :

Tissue:

Eyes

Bone and connective tissue

Skin

Heart

Other:

Limitations:

Organ:

Heart

Kidney(s)

Liver

Lung(s)

Pancreas

Other: .

Signed this _____ day of __________________, ______ .

Signature

Place

If another person is to sign for the declarant at the declarant's direction, the person signing for the declarant must sign in the presence of two persons or a person who is qualified to take acknowledgments under AS 09.63.010 . The witness form below may be used for the two witnesses. The acknowledgement form below may be used for the person qualified to take acknowledgements.

WITNESS FORM

Witness

Address

Witness

Address

State of

Judicial District

ACKNOWLEDGEMENT FORM

The foregoing instrument was acknowledged before me this (date) by (name of person who acknowledged).

Signature of Person Taking Acknowledgement

Title or Rank

Serial Number, if any.

A declaration may be revoked at any time and in any manner by which the declarant is able to communicate an intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care provider acting under the guidance of that physician upon communication to the physician or health care provider by the declarant or by another to whom the revocation was communicated.

The attending physician or health care provider shall make the revocation a part of the declarant's medical record.

Other Forms You May Need

• Alaska General Durable Power of Attorney for Property & Finances (Immediate)
• Alaska General Durable Power of Attorney for Property & Finances (Upon Disability)