ALASKA STATUTORY LIVING WILL
DECLARATION
If I should have an incurable or irreversible condition that will cause my death within a relatively short time, it is my desire that my life not be prolonged by administration of life-sustaining procedures. If my condition is terminal and I am unable to participate in decisions regarding my medical treatment, I direct my attending physician to withhold or withdraw procedures that merely prolong the dying process and are not necessary to my comfort or to alleviate pain.
I (
_____) do (
_____) do not desire that nutrition or hydration (food and water) be provided by gastric tube or intravenously if necessary.
Notwithstanding the other provisions of this declaration, if I have donated an organ under this declaration or by another method, and if I am in a hospital when a do not resuscitate order is to be implemented for me, I do not want the do not resuscitate order to take effect until the donated organ can be evaluated to determine if the organ is suitable for donation.
Other Directions:
_______________________________________________________________________________________________________________________________________________________________________________________________________________
OPTIONAL: In the event of my death, I donate the following part(s) of my body for the (medical) purposes identified in Alaska state law AS 13.50.020:
_____ any needed tissue or organ.
_____ only the following tissues and/or organs:
Tissues:
___ eyes/corneas; ___ bone and connective tissue; ___ skin grafts; ___ heart for valves; ___ additional research tissue. Organs:
___ kidneys; ___ heart; ___ lungs; ___ liver; ___ pancreas. THIS DECLARATION MUST SIGNED BY THE DECLARANT. IF THE DECLARANT CANNOT SIGN AND DIRECTS THAT ANOTHER PERSON SIGN ON THE DECLARANT’S BEHALF, THE SIGNATURE MUST EITHER BE WITNESSED BY TWO PERSONS OR ACKNOWLEDGED BY A PERSON QUALIFIED TO TAKE ACKNOWLEDGMENTS UNDER AS 09.63.010.______________________________________________(Declarant’s Signature)
______________________________________________ (Declarant’s Printed Name)
___________________(Date)
Place signed:
_____________________________________, Alaska.
The foregoing instrument was acknowledged before me this
______ day of
_________________________, 20
______, by:
________________________________________________________Signature of Person Taking Acknowledgment and Title or Rank
OR The declarant is known to me and voluntarily directed another to sign this document in my presence.
______________________________________________(Witness #1’s Signature)
______________________________________________(Witness #1’s Printed Name)
______________________________________________(Address)
______________________________________________(City, State, Zip)
______________________________________________(Witness #1’s Signature)
______________________________________________(Witness #1’s Printed Name)
______________________________________________(Address)
______________________________________________(City, State, Zip)
Use translation clause below if necessary. A physician or health care provider may presume, in the absence of actual notice to the contrary, that this declaration complies with A.S. 18.12.010 and is valid.
TRANSLATION CLAUSE (if needed) I certify that I have translated the provisions of the foregoing Living Will Declaration from the English language to the
_______________________ language to the best of my ability.
______________________________________________(Translator’s Signature)
______________________________________________ (Translator’s Printed Name)
A declaration may be revoked at any time and in any manner by which the declarant is able to communicate an intent to revoke, without regard to mental or physical condition. A revocation is only effective as to the attending physician or any health care provider acting under the guidance of that physician upon communication to the physician or health care provider by the declarant or by another to whom the revocation was communicated. The attending physician or health care provider shall make the revocation a part of the declarant's medical record.
