Mental Health Advance Health Care Directive (Page 3 of 5) in pdf

ALTERNATE AGENT (Optional): If I revoke my agent's authority or if my agent is not

willing, able, or reasonably available to make a health care decision for me, I designate as my

first alternate agent

__________________________________________________________

(name of individual you choose as first alternate agent)

__________________________________________________________

(address) (city) (state) (zip code)

__________________________________________________________

(home telephone) (work telephone)

SECOND ALTERNATE AGENT (Optional) If I revoke the authority of my agent and

first alternate agent or if neither is willing, able, or reasonably available to make a health care

decision for me, I designate as my second alternate agent

__________________________________________________________

(name of individual you choose as second alternate agent)

__________________________________________________________

(address) (city) (state) (zip code)

__________________________________________________________

(home telephone) (work telephone)

(2) AGENT'S AUTHORITY. My agent is authorized and directed to follow my

individual instructions and my other wishes as expressed here or to the extent known to the agent

in making mental health care decisions for me. If these are not known, my agent is authorized

and directed to make these decisions based on:

what I would choose if I were competent, or

my best interests:

________________________________________________________________________

(Add additional sheets if needed.)

Under this authority, "best interest" means that the potential benefits from a treatment

outweigh the risks or detriments resulting from that treatment after assessing

(A) the effect of the treatment on physical, emotional, and cognitive functions;

(B) the degree of physical pain or discomfort caused by the treatment or the

withholding or withdrawal of the treatment;

(D) the quality of life with and without the treatment;

(E) the effect of the treatment on life expectancy with and without the treatment;

(F) the risks, side effects, and potential

of the treatment or the withholding of

benefits

treatment; and

religious beliefs and basic values, to the extent that these may assist in determining

(G)

and

benefits

burdens.

Alaska Mental Health Advance Directive Form

Page 3

(Chapter 38 Session Laws of Alaska 2004)

Courtesy of

Mental Health Advance Health Care Directive Page 3

Related Articles

Related forms

Related Categories