Alaska Advance Health Care Directive Form

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An Alaska advance directive is a document that allows a person to choose up to 2 health care agents to act in their place if they should not be able to speak for themselves. In addition, there is a section that lets a person decide their medical treatments if they should be in a state of permanent incapacitation with no cure. After signing, the form should be kept in a safe and accessible place with the health care agents aware of its location.

Table of Contents

Laws

Statute – AS 13.52.010

Signing Requirements (AS 13.52.010(b)) – Notary public or two (2) witnesses.

State Definition (AS 13.52.390(1)) – “Means an individual instruction or a durable power of attorney for health care.”

Registering

There is only a State registry for organ donation. An advance directive must be kept by the parties. (AS 13.52.177)

Versions (4)


Alaska Division of Public Health

Download: Adobe PDF, MS Word, OpenDocument

 

 

 


Institute for Human Caring

Download: Adobe PDF

 

 

 


Mental Health Advance Directive

Download: Adobe PDF

 

 

 


Providence Health

Download: Adobe PDF

 

 

 


How to Write

Download: Adobe PDF

Part 1 Durable Power Of Attorney For Health Care Decisions

Section 1. Designation Of Agent

(1) Alaska Health Care Agent. It is imperative that the full name of your Alaska Health Care Agent is attached to this role. The first task this directive requests is a report on the name, address, and telephone number of your Alaska Health Care Agent.

(2) Designation Of First Alternate (Optional). A Successor Agent can be held in reserve in case your Alaska Health Care Agent steps down while you are incapacitated, cannot be reached at a time when your directives are essential to survival, or is unable to act on your behalf. This Party can be pre-approved to represent your health care preferences with Alaska Doctors but will not hold any authority to do so beforehand. This appointment requires the name of the Person who should be approached to assume this post, the full address where he or she can be reached, and his or her current telephone number.

(3) Designation Of Second Alternate Agent (Optional). An additional Representative can be identified as a Second Alternate Agent to receive the authority to inform Alaska Doctors of your medical preferences should your current Health Care Agent (Original or Alternate) be unable or unwilling to represent your treatment directives. This Party will be given the power to make medical decisions in your name if or when your Health Care Agent and First Alternate Agent do not occupy this role when needed.

Section 2. Agent’s Authority

(4) Approved Principal Medical Powers. The Alaska Health Care Agent who shall act with your authority over medical treatment decisions will be given the ability to make decisions that fit the situation and your medical condition however you can limit this level of power with directives, instructions, and limitations that you wish applied. Utilize the area in the second section to include such provisions in this appointment.

Section 3. When Agent’s Authority Becomes Effective

(5) Setting The Date Of Effect. The calendar date when your Health Care Agent is first authorized to issue your medical preferences in the State Of Alaska can be set to be the first day that you are incapacitated or upon this document’s execution. It will be assumed that you wish your Health Care Agent’s powers to become effective only when you are incapacitated unless you select the checkbox statement granting immediate powers. If you select the checkbox statement in section 3 the power to act as your Health Care Agent will be granted immediately upon your signing of this document

Section 5. Nomination Of Guardian

(6) Court-Appointed Guardian. This appointment will also name your Health Care Agent and Alternate Health Care Agents as nominations for a court-appointed Guardian. Alaska Courts may determine that a Guardian over your person or Estate Conservator is required to safeguard your interest. You can cross out the fifth section or void it in your attached instructions if you do not wish to nominate your Health Care Agent or intend to nominate additional people. Be advised this paperwork does not obligate Alaska Courts to appoint your nomination as Guardian (or Conservator) but will be taken into consideration.

Part 2 Instructions For Health Care

Section 6. End Of Life Decisions

Select Item 7 Or Item 8

(7) The Choice To Prolong Life. Several crucial topics should be addressed in this paperwork when anticipating a time where you are unable to communicate (i.e., speaking, signing, blinking, etc.) regarding your medical treatment. You can grant the consent Alaska Doctors require to employ life-prolonging treatment when you are incapacitated and unable to survive without such aid by selecting Statement A. If this is not your preference, then do not select the checkbox corresponding to Statement A.

(8) The Choice Not To Prolong Life. A decision to withdraw or deny life-prolonging techniques when your condition is incurable or untreatable and you are unable to communicate can be conveyed to Alaska Medical Personnel using this document. To inform attending Physicians in the State of Alaska of this decision, mark the checkbox attached to Statement B. This decision will require some further definition, therefore if it should be applied to a scenario where you are permanently unconscious, you must select Statement (I) whereas applying your choice to not prolong life can be applied when you have a terminal condition by checking Statement (II). Additional Instructions can be provided as needed in Statement (II).

(9) Alaska Artificial Nutrition And Hydration Instructions. Your decision to accept nutrition and liquids intravenously or through a tube can be delivered by selecting the first option in Statement (C). The second option in this statement declares that you will only accept artificially administered nutrition and liquids indefinitely unless it becomes a burden while the third delivers consent to a trial period in hopes that your condition will improve. If none of these options are an accurate representation of your wishes because you do not consent to receiving artificially delivered nutrition or hydration then select second to last option from the list in Statement C. An opportunity to deliver additional instructions regarding artificially delivered nutrition and liquids is also available as a final option.

(10) Your Pain Management Directive. Alaska Physicians will seek to administer treatment to keep you pain-free when necessary. You can either approve all efforts legally available to Alaska Doctors seeking to manage or lessen the pain you are in or you can give specific instructions on what pain management techniques you consent to receiving or refusing.

(11) Instructions For Pregnancy. A distinct area has been provided so that you may deliver medical treatment instructions and directives should it be discovered that you are pregnant while you are incapacitated or suffering a terminal condition and unable to speak for yourself.

Section 7. Other Wishes

(12) Continued Medical Preferences. An additional area where you can supplement the default directives you declared above has been provided. Here, you may address Alaska Medical Personnel and your Agents on any topic you feel is relevant regarding treatment options that you prefer or wish avoided. Notice that a section where you can place conditions on any treatment or instruction has also been provided.

Part 3 Anatomical Gift At Death

Section 8. Upon Death

(13) Donation Directive. An optional area will enable you to dictate your standing on making anatomical gifts upon your death. You can donate all organs and body parts requested or list specific anatomical donations. Either select Statement (A) or (B) to indicate your decision. If Statement (B) is selected, make sure to provide a list of your anatomical donations.

(14) Donation Purpose. Select the purpose of anatomical donations by selecting it (or them) from the list provided.

(15) Refusal On Anatomical Gift. Select Statement D if you do not wish to be an Organ Donor in the State of Alaska.

Part 4 Mental Health Treatment (Optional)

Section 9. Psychotropic Medication

(16) Medication For Mental Health Directive. The ability to issue your directives for treatment applied to a mental health condition or event that requires attention when you are unable to represent your own wishes has been included. The first topic of psychotropic medications seeks your consent or refusal of such medications in the State of Alaska. By initialing the appropriate statement and providing information, you can name medications that you consent to receive as well as medications that you do not wish administered and intend to refuse.

(17) Conditions Or Limitations. Additional concerns that should be applied to the administration of medications used to treat a mental health condition or event

Section 10 Electroconvulsive Treatment

(18) Consent Or Refuse Electroconvulsive Treatment. You can inform Alaska Medical and Mental Health Professionals of your standing on electroconvulsive therapy should you become unable to effectively or reliably communicate when asked for your consent to this procedure. You can use the tenth section to consent to receiving electroconvulsive therapy whenever necessary, only under certain conditions, only under specific circumstances with limitations applied, or you can refuse electroconvulsive therapy altogether. Select the statement that adequately represents your directives on this matter making sure to include any additional directives, concerns, or limitations that should apply to your choice.

Section 11. Admission And Retention In Facility

(19) Mental Health Hospitalization. There may be a time when Mental Health or Medical Professionals and Responders will seek to treat your symptoms in a Mental Health Facility. You can consent to this admission for a certain number of days (that you report in the space provided) by tending to the first statement in Section 11 or you can refuse admittance to a Mental Health Facility using the second option. You may also add instructions to either of these directives by supplying your own specific limitations on hospitalization.

(20) Other Wishes Or Instructions. Convey your mental health treatment preferences to Alaska Mental Health Providers by documenting them in this paperwork.

(21) Conditions Or Limitations. You can put conditions on any topic you discussed in the additional instructions you provided. This will inform Mental Health Care Professionals of your applicable concerns regarding such instructions.

Part 5. Primary Physician (Optional)

(22) Physician Name And Address. This document can be used to inform attending Medical Responders and Personnel of your Primary Physician’s identity and contact information. To this end, record the full name of your Primary Physician and his or her address then provide the Primary Physician’s telephone number.

(23) Alternate Primary Physician. An alternate to your Primary Physician can be named in this paperwork which can be useful if attending Alaska Medical Personnel require information about your current medical status but cannot reach your Primary Physician.  List the name, address, and phone number of your Alternate Primary Physician for the benefit of future Reviewers.

Section 14 Signatures

(24) Signature Date. Only the calendar date when you sign this document can be considered its formal signature date. Produce this information where requested.

(25) Effective Signature. Your witnessed or notarized signature is the only instrument that can put this document in effect in this State Of Alaska. Sign this document in front of either a Witness or a Notary Public.

(26) Your Birthdate.

(27) Your Name And Address.

Section 15 Witnesses

(28) Dated Signature Witness 1. The first Witness will take control of this document then provide the current date and his or her signature.

(29) Witness 1’s Printed Name And Address.

(30) Dated Signature Witness 2. The second Witness must attest to the authenticity of your signing with his or her own dated signature.

(31) Witness 2’s Printed Name And Address.

Alternative No. 2

(32) Notary Public. If you have opted to sign this document before a Notary Public. He or she will be able to verify your act of signing with his or her testimony and credentials

 

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