Alaska Statutes Sec. 13.52.300 - Optional Form

The following sample form may be used to create an advance health care directive. The other sections of this chapter govern the effect of this or any other writing used to create an advance health care directive. This form may be duplicated. This form may be modified to suit the needs of the person, or a different form that complies with this chapter may be used, including the mandatory witnessing requirements:

ADVANCE HEALTH CARE DIRECTIVE

Explanation

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.

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,

(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;

procedures, and programs of medication;

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

nutrition and hydration and all other forms of health care; and

(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.

After 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 the 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 participate in treatment decisions by means of a rational

thought process.

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:

________________________________________________________________

(name of individual you choose as agent)

________________________________________________________________

(address) (city) (state) (zip code)

________________________________________________________________

(home telephone) (work telephone)

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)

________________________________________________________________

(home telephone) (work telephone)

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)

________________________________________________________________

(home telephone) (work 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:

________________________________________________________________

(Add additional sheets if needed.) 30

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;

the 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) WHEN 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. 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 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 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 of my person 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

INSTRUCTIONS FOR HEALTH CARE

If 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 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 (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 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: ___________________________________

_______________________________________________________________

take 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:

______________________________________________________________

(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

ANATOMICAL GIFT AT DEATH

(OPTIONAL)

If 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, OR

(B) � � I give the following organs, tissues, or other body parts

only _________________________________________________________________

_______________________________________________________________

following you want):

� � (i) transplant;

� � (ii) therapy;

� � (iii) research;

� � (iv) education.

(D) � � I refuse to make an anatomical gift.

PART 4

MENTAL HEALTH TREATMENT

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.

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 of the form. If you do fill out this part of the

form, you may strike any wording you do not want.

(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:

________ 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 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:

________ 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

______________________________________________________________.

Conditions or limitations: _____________________________________

______________________________________________________________.

PART 5

PRIMARY PHYSICIAN

(OPTIONAL)

(12) I designate 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)

(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)

______________________________________________________________.

(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

Witness Who is Not Related to or a Devisee of the Principal

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 code) 30

Witness Who May be Related to or a Devisee of the Principal

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.

____________________________________________________________

(date) (signature of witness)

____________________________________________________________

(printed name of witness)

____________________________________________________________

(address) (city) (state) (zip code) 30

ALTERNATIVE NO. 2

State of Alaska

________ Judicial District

On this ________ day of ____________, in the year ________, before me, _____

________________________ (insert name of notary public) 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.

Notary Seal

____________________________

(signature of notary public)

Section: Previous 13.52.253 13.52.255 13.52.257 13.52.260 13.52.263 13.52.265 13.52.267 13.52.270 13.52.275 13.52.280 13.52.290 13.52.300 13.52.390 13.52.395 Next

Last modified: November 15, 2016