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Advance Directives for Health Care & Mental Health Care for, Alaska

Designating a person to make healthcare decisions on your behalf in the State of Alaska requires the completion of this form. Complete the form and submit it along with any required information.

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A	dvance 	D	irectives for 	H	ealth 	C	are  	
&  	
Mental Health Care 	
 	
for

2 	
 
 
 
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 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; and                                                                   
(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.

3 	
  
 
 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.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
The form that follows is found in AS 13.52.300

4 	
 	
 
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        	
 
 Address        
 	
 	City      	 State    	 Zip    	 
  Home Phone      	
 Work      	                                                              	 	
                                                                                     
                 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        	 
 Address        
 	
 	City      	 State    	 Zip    	 
  Home Phone      	
 Work      	  
                                                                        	
 	
                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        	
 
 Address        
 	
 	City      	 State    	 Zip    	 
  Home Phone      	
 Work      	     
 
 
(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.)

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  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 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.

6 	
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)                                                                                      	
  	
                                         
[  ]  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                                                                                              
[  ]  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: 
_________________________________________________________________ 
_________________________________________________________________

7 	
 
(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.)

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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:                            	
 	
                ____________________________________________________________________	__________                          
                      
My gift under (A) or (B) above is for the following purposes (mark any of the following 
you want):                                                                    
                                 [  ]  transplant;                                                                    
                                 [  ]  therapy;                                                                      
                                 [  ]  research;                                                                    
                                 [  ]  education.  
                                                                   
                           [  ]  (C)  I refuse to make an anatomical gift.  
                                               	
 
 
    	
 
 
 
 
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.   
                                                                                                 
                 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 	
 (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:            
 
         
 
   ___________________________________________________________________

10 	
                                                 	
PART 5 
 
PRIMARY PHYSICIAN 	
(OPTIONAL) 
 
(12)  I DESIGNATE THE FOLLOWING PHYSICIAN AS MY  
  PRIMARY PHYSICIAN:                                                                                                  	
 	
     
  Name of  Physician          	
 
 Address        
 	
 	City      	 State    	 Zip    	 
 Phone    	
                                                                          
 
 
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    	 
 Phone    	
                                                                          
 	
  	
(13) EFFECT OF COPY.  A copy of this form has the same effect as the original.  
 
 
(14) SIGNATURES.     
 
In the presence of the witnesses or notary public, sign and date the form here:  
 
      	
    	 
Signature                                                   Date 	
  	
                        	 
             	
Printed Name 
 	
             	Address        	 	
             	City      	 State    	 Zip    	 	
 
    
(15)  WITNESSES.     
 
This advance care health directive will not	
 be valid for making health care decisions 
unless	
 it is  
                                              
(A)  signed by two (2) 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

11 	
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 
 
 W	
ITNESS 	W	HO 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, 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.   
                                                                  
     	
     	 
Signature of First Witness                                              Date 	
 
                        	
 
             	
Printed Name 	
             	Address        	 	
             	City      	 State    	 Zip    	 	
  
 
W	
ITNESS 	W	HO 	M	AY 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, 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;

12 	
(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.  
                                               
     	
     	 
Signature of Second Witness                                              Date 	
 
                        	
 
             	
Printed Name 	
             	Address        	 	
                          	City      	 State    	 Zip    	 	
 	
 
 
ALTERNATIVE NO. 2 
 
A	
CKNOWLEDGEMENT BY 	NOTARY 	PUBLIC	 
 
 State of Alaska ________________ Judicial District                                                                       
 On this ____ day of ___________________, in the year ______________, before me, 
__________________________________________ (	
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.                                                                                       
 
  
                                           (Seal) 
  
 
 ____________________________________________                                                          	
  Signature of Notary Public       
 
 
 
 
 
 
 
 
 
 
 	
Courtesy	 of 	R	epresentative 	B	ruce 	W	eyhrauch 
A	
laska 	State 	Capital 	
Juneau, 	Alaska 99801 
 
907-465-3744 
 
 	
Paid for by funds available to Rep. Weyhrauch under AS 24.10.110.
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