Alaska Advance Health Care Directive

ADVANCE HEALTH CARE DIRECTIVE

Based on the optional sample form in AS 13.52.300

As a competent adult, 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.

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 it complies with AS 13.52. You may 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 is a psychiatrist), or by both a physician and a professional mental health clinician.

If you name a health care agent, sign and date this form and complete either the two-witness alternative or the Alaska notary alternative. Although Alaska law separately recognizes individual health care instructions without the agent-designation formalities, this complete combined form should be signed and executed using one of the alternatives provided.

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:

Agent

Name: ________________________________________________

Address: ____________________________________________________

City, State, ZIP: __________________________________________

Telephone: ____________________________

Unless related to me, my agent may not be an owner, operator, or employee of a health care institution where I am receiving care.

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:

First alternate agent

Name: ________________________________________________

Address: ____________________________________________________

City, State, ZIP: __________________________________________

Telephone: ____________________________

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:

Second alternate agent

Name: ________________________________________________

Address: ____________________________________________________

City, State, ZIP: __________________________________________

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:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Under this authority, best interest means that the benefits to me resulting from a treatment outweigh the burdens to me resulting from that treatment after assessing:

(A) the effect of the treatment on my physical, emotional, and cognitive functions

(B) the degree of physical pain or discomfort caused to me by the treatment or the withholding or withdrawal of the treatment

(C) the degree to which my 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 my life expectancy

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

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

(G) my religious beliefs and basic values, to the extent that these may assist in determining benefits and burdens

(3) When an agent's authority becomes effective

Unless I mark the following box, the authority of my agent becomes effective only upon a determination that I lack capacity and it ceases to be effective upon a determination that I have recovered capacity. Such a determination shall be made by my primary physician (except in the case of mental illness). In the case of mental illness, such a determination shall be made by a court or my primary physician or another health care provider in the event of an emergency.

☐ 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 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 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. This nomination takes priority over any other nomination I may have made, including a nomination contained in a separate general power of attorney form.

PART 2. INSTRUCTIONS FOR HEALTH CARE (OPTIONAL)

If you are comfortable allowing your agent to determine what is best for you in making health care decisions, you do not need to fill out this part. If you do fill out this part, you may strike any wording you do not want and initial next to the wording you cross out.

There is a separate state protocol that governs physician do not resuscitate orders. A DNR order is a physician directive that emergency cardiopulmonary resuscitation should not be administered. This advance directive is not itself a physician-issued DNR order. You may obtain information about Alaska's Comfort One program from the Alaska Department of Health.

(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. Mark only one of (A) or (B).

☐ (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.

☐ (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 (mark all 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

☐ (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 (mark 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

☐ I give these instructions:

______________________________________________________________

______________________________________________________________

(E) Should I become unconscious and I am pregnant, I direct that:

______________________________________________________________

______________________________________________________________

______________________________________________________________

Note: Under AS 13.52.055, a direction to withhold or withdraw life-sustaining procedures cannot be given effect when the patient is pregnant and lacks capacity, withdrawal would likely result in the patient's death, and the fetus could probably develop to live birth if the procedures continued. That statutory limitation may control despite contrary written instructions.

(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:

______________________________________________________________

______________________________________________________________

PART 3. ANATOMICAL GIFT AT DEATH (OPTIONAL)

If you are satisfied to allow your agent to determine whether to make an anatomical gift at the time of your death, you do not need to fill out this part.

(8) Upon my death (mark applicable boxes)

☐ (A) I give any needed organs, tissues, or other body parts

☐ (B) I only give the following organs, tissues, or other body parts:

______________________________________________________________

______________________________________________________________

☐ (C) My gift is for the following purposes (mark any you want):

☐ (i) transplant

☐ (ii) therapy

☐ (iii) research

☐ (iv) education

☐ (D) I refuse to make an anatomical gift

PART 4. MENTAL HEALTH TREATMENT (OPTIONAL)

The instructions in this part 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 competent and to have 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.

(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 (choose one):

☐ 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 (shock) 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 (choose one):

☐ 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:

______________________________________________________________

______________________________________________________________

______________________________________________________________

PART 5. PRIMARY PHYSICIAN (OPTIONAL)

(12) Primary physician

I designate the following physician as my primary physician:

Name of physician: __________________________________________

Address: ____________________________________________________

City, State, ZIP: __________________________________________

Telephone: ____________________________

Alternate (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 and telephone: ____________________________________

(13) Effect of copy

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

(14) Signature

Sign and date your advance directive here:

Date: ______________________

Sign your name: ________________________________________

Print your name: ________________________________________

Address: ____________________________________________________

City, State, ZIP: __________________________________________

(15) Witnesses or notary

This advance health care directive will not be valid for making health care decisions unless it is either (A) signed by two qualified adult witnesses who are personally known to you and who are present when you sign or acknowledge your signature, or (B) acknowledged before a notary public at a place in Alaska.

Neither witness may 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.

COMPLETE EITHER WITNESS ALTERNATIVE NO. 1 OR THE NOTARY ALTERNATIVE. You need only one path.

WITNESS ALTERNATIVE NO. 1

For witnesses who are not related to the principal and who do not benefit under the terms of the principal's will (at least one witness must meet these limits; both witnesses use this block when both are so qualified).

Witness 1

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: __________________________________________

Witness 2

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: __________________________________________

WITNESS ALTERNATIVE NO. 2 — NOTARY PUBLIC AT A PLACE IN ALASKA

Use this path instead of the two-witness path.

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.

Signature of notary public: ______________________________________

Printed name: ________________________________________

My commission expires: ____________________________

Notary seal / stamp area (leave clear space below for official stamp).