Durable Power Of Attorney For Health Care Decisions Page 6
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12PART 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.)
[ ] (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;
or
[ ] 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:
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