Alaska Living Will
This Living Will is made in accordance with Alaska Statutes, specifically AS 13.52, concerning advance health care directives. This document expresses your wishes regarding medical treatment in the event that you are unable to communicate your preferences.
Personal Information:
- Name: ___________________________________
- Date of Birth: ____________________________
- Address: __________________________________
- Phone Number: ____________________________
Declaration:
I, the undersigned, declare that if I become unable to make my own health care decisions due to a terminal condition, irreversible condition, or persistent vegetative state, I wish to make the following choices regarding my medical treatment:
Health Care Preferences:
- In the event of a terminal condition, I do not wish to receive:
- Life-sustaining treatment (such as resuscitation, mechanical ventilation, etc.)
- Nutrition and hydration through artificial means
- If I am in a persistent vegetative state, I wish to:
- Receive comfort care only
- Not receive any life-prolonging treatments
Additional Instructions:
_________________________________________________________________________________________
_________________________________________________________________________________________
Designation of Health Care Agent:
If I am unable to make my own health care decisions, I appoint the following person as my health care agent:
- Name: ___________________________________
- Address: _________________________________
- Phone Number: ____________________________
Signatures:
This Living Will is effective upon my signature below:
Signature: ___________________________________
Date: ________________________________________
Witnesses:
This document must be signed in the presence of two witnesses who are not related to you and who will not inherit from you:
- Witness 1 Name: ____________________________
- Witness 1 Signature: _______________________
- Date: ____________________________________
- Witness 2 Name: ____________________________
- Witness 2 Signature: _______________________
- Date: ____________________________________