Alaska Living Will
This document serves as a Living Will, designed in accordance with the Alaska Advance Health Care Directive Act (Alaska Statutes §13.52.010 - §13.52.260). It is expressly created to communicate the wishes of the undersigned individual regarding medical treatment preferences in situations where they are unable to make decisions due to incapacity or terminal illness.
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Personal Information
Full Name: ___________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: _______________________ State: AK Zip Code: _______________
Phone Number: _______________________________________________
Email Address: _______________________________________________
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Designation of Health Care Agent (Optional)
This portion of the Living Will is optional and allows the designation of a Health Care Agent, who will make health care decisions on your behalf should you become unable to do so. If you choose not to designate a Health Care Agent, you may skip this section.
Health Care Agent's Full Name: __________________________________
Relationship to You: ___________________________________________
Address: _____________________________________________________
City: _______________________ State: AK Zip Code: _______________
Phone Number: _______________________________________________
Alternate Health Care Agent's Full Name: _________________________
Relationship to You: ___________________________________________
Address: _____________________________________________________
City: _______________________ State: AK Zip Code: _______________
Phone Number: _______________________________________________
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Instructions for Health Care
The following directives outline my wishes regarding medical treatment under circumstances where I am no longer capable of making decisions due to incapacitation or terminal illness. These preferences are to guide my Health Care Agent (if designated), family, and health care providers.
- I DO want to receive the following life-sustaining treatments if my condition is terminally ill and treatment would only prolong the dying process:
- Mechanical ventilation/respiration
- Cardiopulmonary resuscitation (CPR)
- Artificial nutrition (feeding tubes)
- Artificial hydration (IV fluids)
- Any other specific treatments: _______________________________
- I DO NOT want to receive any life-sustaining treatments if my condition is terminally ill and treatment would only prolong the dying process.
- In the event of a non-terminal condition where I am unable to communicate my preferences, the following are my directives:
- Preference regarding the use of dialysis
- Preference regarding the use of ventilation
- Preference regarding the use of feeding tubes
- Any other specific preferences: ____________________________
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Signature and Acknowledgment
I understand that I can revoke or change this document at any time. I acknowledge that this Living Will represents my wishes as of the date signed below.
Date: _________________________________________________________
Signature: ____________________________________________________
Witness (Name and Signature): __________________________________
Date: _________________________________________________________
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