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Alaska Living Will Form (Advance Directive) |
The Alaska living will document, also known as an “advance directive”, facilitates the wishes of a person making their end of life medical decisions by way of writing an official statement through this legal document. The aim of the living will is to convey to the medical practitioner the specific medical treatment the principal would wish to undergo should there arise a time when they, the principal, are unable to do so themselves due to a current medical condition, for example rendered unconscious or in a coma. The living will document can also legally include details of the actual process by which the principal wishes to cause an end to life should the situation require, for example the permanent inability of the principal to sustain a single or several vital life functions.
How to Write
Step 1 – Download and carefully read all of the document before completing the blank fields, the instructions below detail what is required.
Required
Page 1.
- Print full name
- Date of birth
Pages 4-5. Part 1. (1) End of life decisions.
- Initial selection `A`choice to prolong life or `B` choice not to prolong life.
- If selecting section `B` then also initial either `B(i) permanent unconsciousness` or `B(ii)` terminal condition and/or `B(iii)` additional instructions.
- Initial one of the following selections regarding artificial nutrition and hydration `C (i), (ii), (iii), (iv) and/or (v) for other instructions`.
- Agree to the statement provided in section `D` or give instructions regarding relief of pain.
- Give instructions for section `E` regarding consciousness during pregnancy.
(2) Other wishes
Enter details of principals other wishes regarding end of life decisions.
- Option to write alternative personal instructions regarding any issues mention in (1) End of life decisions, also including the option to add special limitations and conditions.
Pages 5-7. Part 2. (3) Designation Of Agent
- Print name of agent
- Address
- Telephone numbers Home/Work
- Cell phone & Pager
- Email address
If the principal wishes up to two auxiliary agents may also be nominated. This is in case of an event due to which the primary agent is unable to carry out the agents duties.
OPTIONAL
- Print name of alternative agent #1
- Address
- Telephone numbers Home/Work
- Cell phone & Pager
- Email address
OPTIONAL
- Print name of alternative agent #2
- Address
- Telephone numbers Home/Work
- Cell phone & Pager
- Email address
Agent`s Authority
- Option to enter the specific wishes of the principal to be carried out by the agent and giving authority to the agent regarding health care decisions should the principal be unable to do so themselves.
Page 7. Part 3. Anatomical Gift Of Death (OPTIONAL)
(8) Upon Death
- Initial section `A` to agree to give any organs, tissues or other body parts.
- Initial section `B` to choose specifically the organs, tissues and other body parts to give. Enter names of these.
- Initial section `C` and relevant items from `i – iv` to describe the specific purposes designated for the anatomical gift upon death.
- Initial section `D` if an anatomical gift is NOT to be given.
Page 8 – 9. Part 4. Mental Health Treatment
9) Psychotropic Medications
- Initial to either give consent for the administration of certain medicines, also to be named here by the principal or initial to not consent to the administration of certain medicines to be named here by the principal.
- Enter requirements for any other conditions or limitations regarding the principal`s mental health treatment.
10) Electroconvulsive Treatment
- Initial either to give consent or to not give consent for the use of electroconvulsive treatment.
- Enter requirements for any other conditions or limitations regarding the principal`s electroconvulsive treatment.
11) Admission To Retention
- Initial either to give consent or to not give consent for admission to and retention in facility.
- Enter requirements for any other conditions or limitations regarding the principal`s admission to and retention in facility .
12) Other Mental Health Wishes Or Instructions
Pages 9 – 11. Part 5. Primaery Physician
13) Details of the primary physician to be treating the principal.
- Enter primary physicians name
- Facility/Office
- Address
- Phone
Optional
Details of the secondary physician to be treating the principal. This is in case of an event due to which the primary physician is unable to carry out the physicians duties.
- Enter secondary physicians name
- Facility/Office
- Address
- Phone
15) Signatures
- Enter the principal`s signature
- Print the Principal`s full name
- Date Completed
- Address
16) Witness
Enter the signatures of two adult witnesses known to the principal.
Alternative #1
- Enter the details of first witness who IS NOT a devisee or relation of the principal.
Required
- Signature
- Printed name
- Date
- Residence address and judicial district
- Enter the details of the second witness who May be a devisee or relation to the principal.
Required
- Signature
- Printed name
- Date
- Residence address and judicial district
Alternative #2 Certificate Of Notarization
- County/Judicial district
- Place
- Day/Month/Year
- Officer name/Title
- Description of any required evidence of identification
- Signature of notary public or officer
- Date commission expires
- Notary seal
