2005 Alaska Statutes
Title 13 DECEDENTS' ESTATES, GUARDIANSHIPS, TRANSFERS, AND TRUSTS
Chapter 13.52. HEALTH CARE DECISIONS ACT
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, 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)

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)