A Guide to Choosing A Durable Power of Attorney
For Health Care
Choosing
Your Agent:
A durable power of attorney for health care allows you to choose the person
who will make decisions about your medical care if you become incapable of
doing so.
You may choose anyone you like to make these decisions for you, but it is
recommended that you not choose your doctor, any of your doctor’s employees,
or any employee of a hospital or nursing home where you might be a patient.
This document will refer to the person you have chosen as your “agent”.
It will also allow you to designate alternates in case the first person
you choose is later unwilling or unable to make these decisions.
Of course, you should ask the person in advance if he or she is willing
to serve as your agent. Remember
that your agent will make choices for you only if you become unable to do so.
Revoking or reinstating an agent’s authority:
a.
A durable power of attorney may be revoked by a mentally competent person but
not by a person who is mentally incompetent.
b.
If revocation or reinstatement is made, the attending physician or other
health care provider shall make the declaration a part of the medical record.
Choosing Medical Care:
After choosing your agent, you can also use this document to indicate the
kinds of medical care you wish to receive or not receive.
You should make certain that your agent understands your wishes.
Completing this Document:
If you have any questions about this document, you should consult with your
doctor or with an attorney. In
addition, you must sign this document in the presence of a Notary Public.
(Your bank, hospital or Alaska Legal Services has a Notary Public who
can notarize this for you.)
Keep this document with your other important papers.
A copy of this document needs to be given to your agent, physician and
hospital.
Durable Power of Attorney For Health Care
Section 1
I,
, of
, do hereby designate and appoint
, of
(telephone #) (
)
as my attorney-in-fact for
health care decisions (hereafter, Agent).
I authorize this Agent to represent me in all health care decisions.
I intend my Agent to have full authority to consent to giving,
withholding or stopping any health care treatment, service or procedure.
Further, my Agent may consent to my admission to a medical, nursing,
residential or other facility and may enter into agreement for my care. My
Agent has the authority to talk with health care personnel, to access and
disclose to other medical and related information and records, and to sign
forms on my behalf.
Section 2
My agent shall make decisions with my desires as expressed here.
(Select any of the following statements that reflect your desires.
You may choose more than one, but should cross out and initial those
statements you DO NOT agree with.)
o
I want my life to be prolonged to the greatest extent possible without regard
to pain, discomfort, or cost incurred or the chances I have for recovery.
o
I want my life to be prolonged and I want life prolonging treatment to be
provided unless, in my Agent’s judgment, the pain, discomfort, or probable
outcome of the treatment outweigh any benefit the treatment may have for me.
o
If I should be in an incurable, irreversible physical condition with no hope
of survival, I do not want any treatment that will merely prolong my dying.
Thus, I want my treatment limited to medical and nursing measures that
are intended to keep me comfortable to relive pain and to maintain my dignity.
o
If I am in a coma or vegetative state which my doctor reasonably believes to
be permanent, I do not want any life-prolonging treatment to be started or
continued, including devices to provide artificial nutrition or hydration.
o
I have other instructions for my care. They are listed below:
(You may add any other instructions here. Put a line through the space that
you do not use.)
By completing this document, I intend to create a durable power of attorney
for health care under Alaska Statutes 13.26.325.
It shall take effect upon my incapacity to make my own health care
decisions and shall continue during that incapacity to the extent permitted by
law or until I revoke it.
This durable power of attorney may be revoked by me at any time so long as I
am mentally competent to do so.
Please initial appropriate box.
o
I have executed a separate “Living Will” under AS 18.12.010.
o
I have not executed a separate “Living Will” under AS 18.12.010.
My wishes concerning the kinds of medical care I do or do not wish to receive
if I should have an incurable or irreversible condition are incorporated
herein.
Section 3
If the person designated as my Agent in Section 1 is unable or unwilling to
act as my Agent, or if I revoke that person’s authority to act as my Agent, I
then designate and appoint, in the order listed below, the following persons
to serve as my Agent to make health care decisions for me.
First Alternate Agent:
Name:
Street Address:
City, State and Zip Code:
Phone: (
)
Area Code
Second Alternate Agent:
Name:
Street Address:
City, State and Zip Code:
Phone: (
)
Area Code
By signing this document, I indicate that I understand the purpose and effect
of this durable power of attorney for health care.
(You must sign this in the presence of a Notary Public.)
Dated this
day of
, 200
.
Signature
Print Name
Address
City, State and Zip
State of Alaska
)
)
ss
Judicial District
)
The foregoing instrument was acknowledged before me by
This
day of
, 20
, at
, Alaska.
(Signature of Person Taking Acknowledgment)
(Title or Rank)
My commission Expires:
This Declaration Must Be Acknowledged By A Person Qualified To Take Acknowledgments Under Alaska Statutes 09.63.010.