Alaska Living Will Template
This Alaska Living Will is a legal document that sets forth your wishes regarding medical treatment in the event that you are unable to communicate or make decisions. In accordance with the Alaska Statutes, specifically AS 13.52 (Alaska Advance Health Care Directive Act), this document allows you to dictate your preferences for medical treatments, including end-of-life care and life-sustaining measures.
Personal Information
Full Name: ___________________________________________________________
Address: ___________________________________________________________
City, State, Zip: ___________________________________________________________
Date of Birth: ___________________________________________________________
Social Security Number: ___________________________________________________________
Health Care Directives
I, ________________ (the "Principal"), being of sound mind, hereby set forth my directives concerning medical treatments and life-sustaining measures as follows:
Treatment Preferences
Should I be in a state that I can no longer make decisions regarding my medical treatment, my preferences are as follows:
- __ I wish to receive all forms of life-sustaining treatment and medical interventions that could extend my life, including artificial nutrition and hydration.
- __ I wish to decline all forms of life-sustaining treatment if there is no reasonable expectation of my recovery from a physical or mental condition and wish to receive only treatments that provide comfort care and relieve pain.
Artificial Nutrition and Hydration
As part of my living will:
- __ I consent to the use of artificial nutrition and hydration to prolong my life, regardless of my condition.
- __ I refuse the use of artificial nutrition and hydration if the burden outweighs the expected benefits, or if I am in a persistent vegetative state with no reasonable expectation of recovery.
Health Care Agent
I designate the following individual as my Health Care Agent to make medical decisions on my behalf should I become unable to make them myself:
Name: ___________________________________________________________
Relationship: ___________________________________________________________
Address: ___________________________________________________________
Phone Number: ___________________________________________________________
In the event that my primary Health Care Agent is unwilling or unable to serve, I designate the following alternate:
Name: ___________________________________________________________
Relationship: ___________________________________________________________
Address: ___________________________________________________________
Phone Number: ___________________________________________________________
Signatures
This Living Will shall be effective upon the signature of the Principal and remain in effect unless revoked. All of my directives set forth in this document are consistent with my desires regarding my healthcare treatment.
______________________________
Signature of Principal
Date: ________________________
______________________________
Signature of Witness #1
Date: ________________________
______________________________
Signature of Witness #2
Date: ________________________
This document was signed in the presence of two adult witnesses, who are not entitled to any portion of the estate of the person signing the Alaska Living Will, are not the health care agent or alternate, and are not directly involved in the provision of health care to the individual.