Alaska Durable Power Of Attorney For Health Care Decisions (Page 2 of 8) in pdf

(D) the effect of the treatment on your life expectancy;

(E) your prognosis for recovery, with and without the treatment;

(F) the risks, side effects, and benefits of the treatment or the withholding of treatment; and

(G) your religious beliefs and basic values, to the extent that these may assist in determining

benefits and burdens.

(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE.

Except in the case of mental illness, my agent's authority becomes effective when my primary

physician determines that I am unable to make my own health care decisions unless I mark the

following box.

In the case of mental illness, unless I mark the following box, my agent's authority becomes effective

when a court determines I am unable to make my own decisions, or, in an emergency, if my primary

physician or another health care provider determines I am unable to make my own decisions.

If I mark this box [ ], my agent's authority to make health care decisions for me takes effect immediately.

(4) AGENT'S OBLIGATION.

My agent shall make health care decisions for me in accordance with this durable power of attorney for

health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my

agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in

accordance with what my agent determines to be in my best interest. In determining my best interest, my

agent shall consider my personal values to the extent known to my agent.

(5) NOMINATION OF GUARDIAN.

If a guardian of my person needs to be appointed for me by a court, I nominate the agent designated in

this form. If that agent is not willing, able, or reasonably available to act as guardian, I nominate the

alternate agents whom I have named under (1) above, in the order designated.

PART 2

INSTRUCTIONS FOR HEALTH CARE

If you are satisfied to allow your agent to determine what is best for you in making health care

decisions, you do not need to fill out this part of the form.

If you do fill out this part of the form, you may strike any wording you do not want. There is a state

protocol that governs the use of do not resuscitate orders by physicians and other

health care providers. You may obtain a copy of the protocol from the Alaska Department of Health and

Social Services. A "do not resuscitate order" means a directive from a licensed physician that emergency

cardiopulmonary resuscitation should not be administered to you.

(6) END-OF-LIFE DECISIONS.

Except to the extent prohibited by law, I direct that my health care providers and others involved in my

care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

(Check only one box.)

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Alaska Durable Power Of Attorney For Health Care Decisions Page 2