ADVANCE DIRECTIVE FOR HEALTH CARE
(Living Will and Health Care Proxy)

Section 1. Living Will

I, [NAME], being of sound mind and at least 19 years old, would like to make the following wishes known. I direct that my family, my doctors and health care workers, and all others follow the directions I am writing down. I understand that these directions will only be used if I am not able to speak for myself.

IF I BECOME TERMINALLY ILL OR INJURED

Terminally ill or injured is when my doctor and another doctor decide that I have a condition that cannot be cured and that I will likely die in the near future from this condition.

Life sustaining treatment includes drugs, machines, or medical procedures that would keep me alive but would not cure me.

I want to have life sustaining treatment if I am terminally ill or injured.
[INITIALS] Yes [INITIALS] No

I understand that if I am terminally ill or injured I may need to be given food and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me.

I want to have food and water provided through a tube or an IV if I am terminally ill or injured.
[INITIALS] Yes [INITIALS] No

IF I BECOME PERMANENTLY UNCONSCIOUS

Permanent unconsciousness is when my doctor and another doctor agree that within a reasonable degree of medical certainty I can no longer think, feel anything, knowingly move, or be aware of being alive.

I want to have life-sustaining treatment if I am permanently unconscious.
[INITIALS] Yes [INITIALS] No

I want to have food and water provided through a tube or an IV if I am permanently unconscious.
[INITIALS] Yes [INITIALS] No

Section 2. If I need someone to speak for me.

This form can be used in the State of Alabama to name a person you would like to make medical or other decisions for you if you become too sick to speak for yourself. This person is called a health care proxy.

[INITIALS] I do not want to name a health care proxy. (If you check this answer, go to Section 3)
[INITIALS] I do want the person listed below to be my health care proxy. I have talked with this person about my wishes.

First choice for proxy: [NAME]
Relationship to me: [RELATIONSHIP]
Address: [ADDRESS]
City: [CITY] State: [STATE] Zip: [ZIP CODE]
Day-time phone number: [PHONE NUMBER] Night-time phone number: [PHONE NUMBER]

Instructions for Proxy

• I want my health care proxy to make decisions about whether to give me food and water through a tube or an IV.
  [INITIALS] Yes [INITIALS] No
• [INITIALS] I want my health care proxy to follow only the directions as listed on this form.
• [INITIALS] I want my health care proxy to follow my directions as listed on this form and to make any decisions about things I have not covered in the form.
• [INITIALS] I want my health care proxy to make the final decision, even though it could mean doing something different from what I have listed on this form.

Section 3. The things listed on this form are what I want.

I understand the following:

• If my doctor or hospital does not want to follow the directions I have listed, they must see that I get to a doctor or hospital who will follow my directions.
• If I am pregnant, or if I become pregnant, the choices I have made on this form will not be followed until after the birth of the baby.
• If the time comes for me to stop receiving life sustaining treatment or food and water through a tube or an IV, I direct that my doctor talk about the good and bad points of doing this, along with my wishes, with my health care proxy, if I have one, and with the following people: [NAMES]

Section 4. My signature

Your name: _________________________

The month, day, and year of your birth: [DAY] day of [MONTH], [YEAR]

Your signature: _______________________

Date signed: [DAY] day of [MONTH], 20[XX]

Section 5. Witnesses (need two witnesses to sign)

I am witnessing this form because I believe this person to be of sound mind. I did not sign the person’s signature, and I am not the health care proxy. I am not related to the person by blood, adoption, or marriage and not entitled to any part of his or her estate. I am at least 19 years of age and am not directly responsible for paying for his or her medical care.

Name of first witness: ___________________

Signature: _____________________________

Date: [DAY] day of [MONTH], 20[XX]

Name of second witness: _________________

Signature: _____________________________

Date: [DAY] day of [MONTH], 20[XX]

Section 6. Signature of Proxy

I, ______________________, am willing to serve as the health care proxy.

Signature: ____________________ Date: [DAY] day of [MONTH], 20[XX]