Advance Directive for Health Care - Alaska

The Alaska Advance Health Care Directive released by the Alaska Department of Health and Social Services is a crucial form that allows of-age individuals to have legal control over their medical treatment in the event when they are unable to speak for themselves. Download a ready-made directive through the link below or make your own form with our customizable template.

The document provides an efficient and flexible format for planning out future health care and gives patients the option of electing a trusted individual or health professional to oversee their care. There is a difference between an Alaska Advance Directive for Health Care and an Alaska Living Will. The former are oral or written instructions about future medical care in case the individual becomes too ill to communicate. The latter is a specific type of directive that takes effect only when a patient is terminally ill.

An Alaska Advance Directive is defined by AS 13.52.010 and regulated by Chapter 52 (Health Care Decisions Act). The document may be oral or written. Any advance health care directive made in compliance with the laws of another state is valid in the state of Alaska.

ADVERTISEMENT

Download Advance Directive for Health Care - Alaska

343 times
Rate
4.6(4.6 / 5) 24 votes
Alaska Advance Health Care
Directive
This booklet contains the Alaska statutory form for an
Advance
Health
Care
Directive.
Alaska
Legal
Services
Corporation (ALSC) provides this as a service to you and
does not take responsibility for how you fill it out. The law
allows you to prepare this form on your own. This booklet
contains general information to assist you. However, if you
have questions,
please
contact
an
attorney
or
other
knowledgeable source. The Alaska Bar Association’s
Lawyer Referral Service can provide you with a list of
private
attorneys
(272-0352
or
1-800-770-9999
outside
Anchorage). If you cannot afford an attorney or if you are 60
years
or
older,
ALSC
may
be
able
to
assist
you.
Anchorage 272-9431 or (888) 478-2572; Bethel 543-2237 or
(800) 478-2230; Dillingham 842-1452 or (888) 383-2448;
Fairbanks 452-5181 or (800) 478-5401; Juneau 586-6425 or
(800) 789-6426; Kenai 395-0352 or (855)-395-0352; Ketchikan
225-6420 or (877) 525-6420; Kotzebue 442-7737 or (877)
622-9797;
Nome
443-2230
or
(888)
495-6663;
Palmer
(746-4636) or (855) 996-4636; or Utqiagvik (Barrow) (855-8998)
or (855) 755-8998.
This booklet is provided by the Alaska Legal Services Corporation, a statewide
private nonprofit organization. Nothing contained in this publication is to be
considered as the rendering of legal advice for specific cases and readers are
responsible for obtaining such advice from an attorney.
Funding for this brochure came from the State of Alaska, Department of Health
and Social Services, Division of Senior and Disabilities Services.
For information regarding many other legal topics, see www.alaskalawhelp.org
Printed January 2017
Alaska Advance Health Care
Directive
This booklet contains the Alaska statutory form for an
Advance
Health
Care
Directive.
Alaska
Legal
Services
Corporation (ALSC) provides this as a service to you and
does not take responsibility for how you fill it out. The law
allows you to prepare this form on your own. This booklet
contains general information to assist you. However, if you
have questions,
please
contact
an
attorney
or
other
knowledgeable source. The Alaska Bar Association’s
Lawyer Referral Service can provide you with a list of
private
attorneys
(272-0352
or
1-800-770-9999
outside
Anchorage). If you cannot afford an attorney or if you are 60
years
or
older,
ALSC
may
be
able
to
assist
you.
Anchorage 272-9431 or (888) 478-2572; Bethel 543-2237 or
(800) 478-2230; Dillingham 842-1452 or (888) 383-2448;
Fairbanks 452-5181 or (800) 478-5401; Juneau 586-6425 or
(800) 789-6426; Kenai 395-0352 or (855)-395-0352; Ketchikan
225-6420 or (877) 525-6420; Kotzebue 442-7737 or (877)
622-9797;
Nome
443-2230
or
(888)
495-6663;
Palmer
(746-4636) or (855) 996-4636; or Utqiagvik (Barrow) (855-8998)
or (855) 755-8998.
This booklet is provided by the Alaska Legal Services Corporation, a statewide
private nonprofit organization. Nothing contained in this publication is to be
considered as the rendering of legal advice for specific cases and readers are
responsible for obtaining such advice from an attorney.
Funding for this brochure came from the State of Alaska, Department of Health
and Social Services, Division of Senior and Disabilities Services.
For information regarding many other legal topics, see www.alaskalawhelp.org
Printed January 2017
ADVANCE HEALTH CARE DIRECTIVE
Alaska Statutes 13.52
Introduction
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
Advance Health Care Directive page 2 of 13
(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.
Advance Health Care Directive page 3 of 13
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)
_________________________________________________________
(telephone contact)
DESIGNATION OF FIRST ALTERNATE (OPTIONAL): If I
revoke my agent's authority or if my agent is not willing, able, or reasonably
available to make a health care decision for me, I designate as my first alternate
agent
_________________________________________________________
(name of individual you choose as first alternate agent)
_________________________________________________________
(address) (city) (state) (zip code)
_________________________________________________________
(telephone contact)
DESIGNATION OF SECOND ALTERNATE (OPTIONAL): If I
revoke the authority of my agent and first alternate agent or if neither is willing,
able, or reasonably available to make a health care decision for me, I designate as
my second alternate agent
_________________________________________________________
(name of individual you choose as second alternate agent)
_________________________________________________________
(address) (city) (state) (zip code)
_________________________________________________________
(telephone contact)
Advance Health Care Directive page 4 of 13
(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
Advance Health Care Directive page 5 of 13
ADVERTISEMENT

What Is an Alaska Advance Directive?

An Advance Directive is a series of forms that specify an individual's medical treatment preferences and become effective if the individual becomes terminally ill, is seriously injured, in the late stages of dementia or in a coma. The document includes a Living Will and a Medical Power of Attorney - otherwise known as a health care power of attorney or a health care proxy.

  1. Living Wills and written for health care professionals and specify the types of life-prolonging treatments or procedures to perform if the individual is in a terminal condition or in a persistent vegetative state.
  2. A Medical Power of Attorney allows the individual to name a health care proxy to make medical decisions if they become unable to make those decisions for themselves. It is important that the designated proxy knows and understands the patient's wishes and preferences and has a written copy of the Advance Directive for health care.

How to Write an Advance Directive in Alaska?

Advance Care planning is a five-step process:

STEP 1 - Electing an agent to make health care decisions on the patient's behalf.

STEP 2 - Expressing wishes about any limitations in medical treatment - CPR, breathing machines, feeding tubes, and antibiotics.

STEP 3 - Making decisions related to organ and tissue donation and stating preferences regarding the funeral, burial and the disposition of remains.

STEP 4 - Signing, dating and witnessing the form according to the applicable Alaska law. Copies of the completed form should be handed out to the agent, the physician, the patient's family, and the health care facility.

Page of 13