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Alaska Advance Health Care Directive (Living Will) Form |
The Alaska advance health care directive is a legal document that will allow an individual to make and record in writing, their own health care decisions in the event they should ever face any terminal disease or find that they are unable to express their health care choices with their medical team. The Principal may also use this document to appoint someone they trust, (and an alternate should they so desire), to work with their health care provider(s) on their behalf if needed. The health care representative would be available to see to it that the Principal’s end of life wishes are honored as they are expressed and witnessed within the document.
Laws – § 13.52.010
How to Write
Step 1 – Download the document and begin by reading the introduction information
Step 2 – Part 1 – Choosing a Health Care Agent – Read the definitions with regard to the required information in this section, then submit the following:
- Enter the Agent’s first name
- Last name
- Street address
- City
- State
- Zip Code
- Home Telephone Number
- Work Telephone Number
In the event the first agent should become unwilling or unable to carry out the duties related to this document, the Principal may appoint two more alternate agents in the next two sections (Optional):
- Enter the Agent’s first name
- Last name
- Street address
- City
- State
- Zip Code
- Home Telephone Number
- Work Telephone Number
If the Principal would like to specifically state what the health care agent(s) may have permission to do, they may enter this information into the lines provided
In the final portion of this section, the Principal may place an “X” into the box proceeding one of the statements provided that would best indicate the Principal’s decision as to when the health care agent(s) may begin making decisions on their behalf
Step 2 – Part 2 – The Principal may make their own health care decisions in this section. First, the Principal must think about what makes their life worth living in their own opinion:
- To begin, the Principal must place an “X” in all of the sentences that they agree with. The Principal may add additional statements by checking “Other” in any of the sections in the document and entering the information into the lines provided or by adding a sheet to the document with additional statements
- In Part 2 – section 5 – End of Life Decisions – Read the entire page before proceeding
- Place an “X” next to either A or B
- Next, should the Principal chooses not to prolong their life, initial each statement that would be applicable to their wishes
- At the end of section 5, should there be any additional, end of life instructions, enter them into the lines provided
Part 2 – Section 7 – Relief from Pain –
- Adequate pain relief will be assumed to be necessary unless the Principal would prefer other methods. If so, enter alternative selections in the lines provided
Part 2 – Section 8 – Other Wishes –
- Should the Principal have additional instructions to share with their medical team or health care agent, enter these wishes into the lines provided
Step 3 – Part 3 – Anatomical Gifts at Death – (Optional) – This section will address organ and/or tissue donation – If the Principal should choose not to participate, simply leave the section blank. The Principal should indicate their wishes:
- Place an “X” next to the box(es) that best reflect their wishes with regard to anatomical donations of any kind (A through D)
Step 4 – Part 4 – Signatures and Acknowledgement –
- Before the form shall become effective, either the Principal or two (2) witnesses must sign this form. Click the bubble next to the Principal’s preference. If there are no witnesses, a notary public shall suffice
Dated Signature –
- Principal’s full name signature
- Date signature in mm/dd/yyyy format
- Printed name
- Date of Birth in mm/dd/yyyy format
- Social Security Number
- Address
- City
- State
- Zip Code
Witnesses Signatures or Notarization – Witness signatures must not be blood related providing the following (respective) information:
- Witnesses signatures
- Date of signature in mm/dd/yyyy format
- Printed first name
- Printed last name
- Street address
- City
- State
- Zip Code
- Home Telephone
- Work Telephone
Notarization – Should the Principal have no witnesses or prefer to utilize the services of a notary public –
- Print the document and take it to a notary public. This should only be used if two witnesses have not signed the form
- The notary shall then acknowledge the document by completing the Notary Public portion of the document, providing the notary’s signature and the date in which their signature is provided.
