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,


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;


(c) approve or disapprove proposed diagnostic tests, surgical


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.)


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;


(C) the degree to which your 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 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: __________________________________


_______________________________________________________________


(C) Artificial Nutrition and Hydration. If I am unable to safely


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 ________________________________________________________________


_______________________________________________________________


(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.


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)


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)