Alaska Durable Power Of Attorney For Health Care Decisions (Page 3 of 8) in pdf

Alaska Durable Power Of Attorney For Health Care Decisions Page 3

[ ] (A) Choice To Prolong Life I want my life to be prolonged as long as possible within the limits of

generally accepted health care standards; OR

[ ] (B) Choice Not To Prolong Life I want comfort care only and I do not want my life to be prolonged

with medical treatment if, in the judgment of my physician, I have (check all choices that represent your

wishes)

[ ] a condition of permanent unconsciousness: a condition that, to a high degree of medical certainty,

will last permanently without improvement; in which, to a high degree of medical certainty, thought,

sensation, purposeful action, social interaction, and awareness of myself and the environment are absent;

and for which, to a high degree of medical certainty, initiating or continuing life-sustaining procedures for

me, in light of my medical outcome, will provide only minimal medical benefit for me;

[ ] a terminal condition: an incurable or irreversible illness or injury that without the administration of

life-sustaining procedures will result in my death in a short period of time, for which there is no

reasonable prospect of cure or recovery, that imposes severe pain or otherwise imposes an inhumane

burden on me, and for which, in light of my medical condition, initiating or continuing life-sustaining

procedures will provide only minimal medical benefit;

[ ] additional instructions:

fluids (check your choices or write your instructions),

[ ] I wish to receive artificial nutrition and hydration indefinitely;

[ ] I wish to receive artificial nutrition and hydration indefinitely, unless it clearly increases my

suffering and is no longer in my best interest;

[ ] I wish to receive artificial nutrition and hydration on a limited trial basis to see if I can

improve;

[ ] In accordance with my choices in (6)(B) above, I do not wish to receive artificial nutrition

and hydration.

[ ] Other instructions

America Living Will Registry, LLC • 2814 Beach Boulevard South • St. Petersburg, FL 33707 • 866-305-ALWR • •

Alaska Durable Power Of Attorney For Health Care Decisions Page 3