ADVANCE HEALTH CARE DIRECTIVE

Part I: Health Care Agent

If I cannot make my own health care decisions/choices as determined by my health care team, I trust the following person(s) to make my health care choices for me. This person is at least 18 years of age and is NOT my health care provider or employed by my health care provider (unless related by birth, marriage or adoption).

My Health Care Agent is my (relationship): [HEALTH CARE AGENT’S NAME]
Agent’s Name: [NAME] Phone: [PHONE]
Address: [ADDRESS, STREET] City/State/Zip: [CITY/STATE/ZIP CODE]

If the above person is not willing or able to speak for me, I choose the following person as my Alternate Health Care Agent.

My Alternate Health Care Agent is my (relationship): [HEALTH CARE AGENT’S NAME]
Alternate Name: [NAME] Phone: [PHONE]
Address: [ADDRESS, STREET] City/State/Zip: [CITY/STATE/ZIP CODE]

To the extent allowed by Alaska law, (unless crossed out below) my Health Care Agent has the right to:

1. Consent to or refuse any medical care, treatment, service or procedure.
2. Make all health care decisions for me including looking at my medical records and personal papers.
3. Apply for medical financial aid programs such as Medicaid and Medicare or other benefits for me.
4. Make medical choices for me or take legal action to carry out my medical wishes. These wishes are based on instructions that I have given in this form or what I have told him/her is important to me.

Part II: Instructions for Health Care

If a time comes that I am very sick and not able to make my own health care choices or decisions, I want my medical providers and Health Care Agent to respect and follow my wishes as they are written here even if they are different than his or her own. I understand that whatever my health care choices are, I will get the best care possible. If I have a serious injury or illness that cannot be cured, the following is most important to me (initial the one that matters most to you):

[INITIALS] – The length of my life is most important to me even if it means I need extended intensive care and life support.
[INITIALS] – The quality of life is most important to me. I wish to avoid extended intensive care and life support.

If I have a serious injury or illness that cannot be cured, I would not want my life prolonged if (you may initial more than one):

[INITIALS] – I am not able to care for myself (feed, bathe, toilet, and dress without help).
[INITIALS] – I cannot think clearly or make my own decisions.
[INITIALS] – I do not recognize or cannot interact with my loved ones,
[INITIALS] – I am showing signs of suffering that cannot be relieved.

My medical preferences at the end of my life are (initial the one that matters most to you):

[INITIALS] – If possible, I wish to spend the last days of my life at home or in a home-like setting where I can be cared for by my family and friends.
[INITIALS] – If possible, I wish to spend the last days of my life in the hospital or a medical home.
[INITIALS] – Let my Health Care Agent decide.

In the last days of my life, these are important things to know (examples include personal messages, sharing ways to care, music to play, people you wish to see and/or spiritual practices/readings): [DESCRIBE]

After my death (initial the one that matters most to you):

[INITIALS] – I want to donate any needed organs or tissues.
[INITIALS] – I want to donate only the following organs or tissues: [SPECIFY]
[INITIALS] – I do not want to donate any of my organs or tissues
[INITIALS] – Let my Health Care Agent decide.

After my death I want (initial the one that matters most to you):

[INITIALS] – To be buried
[INITIALS] – To be cremated
[INITIALS] – I want my loved ones to decide
[INITIALS] – I want my final resting place to be: [DESCRIBE]

Cardiopulmonary Resuscitation (CPR)

In the event that my heart stops beating and my breathing stops (initial the one that matters most to you):

[INITIALS] I want CPR. I want to try to be resuscitated no matter how sick or injured I am.
[INITIALS] I want CPR unless I have any of the following:

• • An injury or illness that cannot be cured, and I am dying.
  • No reasonable chance for surviving my illness or injury.
  • Little chance for survival and my medical providers think CPR would be more harmful than helpful.

[INITIALS] I do not want CPR. If my heart stops beating or my breathing stops, I wish to allow natural death.

Life Support Treatments

Life support treatments include any medical test, blood product, surgery, procedure, machine and/or medicine needed to prolong life. Inial the one that matters most to you:

[INITIALS] I want life support treatments to help me live as long as possible when medically appropriate.
[INITIALS] I want to try life support treatments to see if I will get better, but I want them stopped if I am not getting better or it is clearly adding to my suffering.
[INITIALS] I do not want life support treatments. I wish to allow natural death with medical treatments focused on providing comfort only.

ARTIFICIAL NUTRITION

In the event that I am unable to communicate or speak for myself and I am not able to eat food or drink fluids safely on my own (initial the one that matters most to you):

[INITIALS] I want artificial nutrition when medically appropriate unless it is clearly adding to my suffering.
[INITIALS] I want to try artificial nutrition for a short time to see if my condition improves, but I want it stopped if I am not getting better.
[INITIALS] I do not want artificial nutrition. Other wishes: [DESCRIBE]

MAKING YOUR ADVANCE HEALTH CARE DIRECTIVE LEGAL

Do not sign your Advance Health Care Directive until you are in front of both witnesses or a notary public.

This Advance Health Care Directive is to be used if/when I am no longer able to make my own medical decisions or speak for myself within the laws of the State of Alaska. I understand my health care rights and choices, and I am signing this Advance Health Care Directive without stress or influence from others. Any Advance Health Care Directive I have done before this date is no longer valid.

Signature: _______________________ Date: [DAY] day of [MONTH], 20[XX]
Name: _______________________ Date of Birth: [DAY] day of [MONTH], [YEAR]

Witness Acknowledgment

I, the witness, personally know the person who filled out this Advance Health Care Directive, and I am not the person’s Health Care Agent. The above person has signed this paper in my presence, and he/she appears to be clear thinking and without stress or influence from others.

Signature of Witness #1:  _______________________ Date: [DAY] day of [MONTH], 20[XX]
Printed Name: ______________________________ Phone: ___________
Address: __________________________________

Signature of Witness #2: _______________________ Date: [DAY] day of [MONTH], 20[XX]
Printed Name: ______________________________ Phone: ___________
Address: __________________________________