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This chapter may be cited as the Health Care Decisions Act. A copy of a written advance health care directive, revocation of an advance health care directive, or designation or disqualification of an agent or a surrogate has the same effect as the original. When determining the best interest of a patient under this chapter, health care treatment may not be denied to a patient because the patient has a disability or is expected to have a disability. In the case of mental illness, nothing in this chapter may be construed to override or undermine the validity of a properly executed durable power of attorney for health care. Each hospital in this state, after consultation with other hospitals and procurement organizations, shall establish agreements or affiliations for coordination of procurement and use of human bodies and parts. If a provision of this chapter, or the application of this chapter to a person or circumstance is held invalid,
including being held unconstitutional, the invalidity does not affect the other provisions or applications of this chapter that can be given effect without the invalid provision or application. A person who has withdrawn as an agent may rescind the withdrawal by executing an acceptance after the date of the withdrawal. A person who rescinds a withdrawal shall give notice to the principal if the principal has capacity or to the principal's health care provider if the principal does not have capacity. As a condition of receiving or being insured for health care services, a health care provider, a health care institution, a health care service plan, an insurer issuing health insurance, a self-insured employee welfare benefit plan, or a nonprofit hospital plan may not require an individual to execute a health care directive, obtain a do not resuscitate order from a physician, or possess do not resuscitate identification. Unless there is a durable power of attorney for health care or another writing clearly expressing an individual's intent to the contrary, an agent or surrogate may not consent on behalf of a patient to an abortion, sterilization,
psychosurgery, or removal of bodily organs except when the abortion, sterilization, psychosurgery, or removal of bodily organs is necessary to preserve the life of the patient or to prevent serious impairment of the health of the patient. Whether a patient has a qualifying condition under this chapter shall be determined by the primary physician of the patient and by at least one other physician, when another physician is available. A physician making the determination shall document the grounds for the determination in the patient's medical record. Permanent unconsciousness shall be determined in consultation with a neurologist. (a) A person may not knowingly, for valuable consideration, sell or purchase a part for any purpose.
(b) In (a) of this section, 'valuable consideration' does not include reasonable payment for the removal, processing,
disposal, preservation, quality control, storage, transportation, or implantation of the part or entire body.
(c) A person who violates this section is guilty of a class C felony.
Section 13.52.170
- 13.52.280 apply to a document of gift, revocation,
or refusal to make an anatomical gift signed by the donor or a person authorized to make or object to making an anatomical gift before, on, or after January 1, 2005. A do not resuscitate order or a do not resuscitate identification executed, issued, or authorized in another state or a territory or possession of the United States in compliance with the law of that jurisdiction is recognized for the purposes of this chapter. However, the do not resuscitate order or the do not resuscitate identification may be implemented only to the extent that the implementation does not conflict with the laws of this state. (a) A guardian shall comply with the ward's individual instructions and may not revoke a ward's advance health care directive executed before the ward's incapacity unless a court expressly authorizes the revocation.
(b) Unless there is a court order to the contrary, a health care decision of an agent takes precedence over that of a guardian.
(c) Except as provided in (a) of this section, a health care decision made by a guardian for the ward is effective without judicial approval.
On petition of a patient, the patient's agent, guardian, or surrogate, or a health care provider or institution involved with the patient's care, the superior court may enjoin or direct a health care decision or order other equitable relief. A proceeding under this section is governed by Section 13.26.165
- 13.26.320. (a) Unless otherwise specified in an advance health care directive, a person then authorized to make health care decisions for a patient has the same rights as the patient to request, receive, examine, copy, and consent to the disclosure of medical or other health care information.
(b) Notwithstanding (a) of this section, if there is a question about the principal's capacity, an agent or a surrogate of the principal may immediately access the personal health care information necessary to determine the principal's capacity, even if the agency or surrogacy does not become effective until the principal lacks capacity.
Section 13.52.170
- 13.52.280 shall be applied and construed to carry out their general purpose to make uniform the law with respect to the subject of Section 13.52.170
- 13.52.280 among states enacting these provisions. (a) Delivery of a document of gift during the donor's lifetime is not required for the validity of an anatomical gift.
(b) If an anatomical gift is made to a designated donee, the document of gift, or a copy, may be delivered to the donee to expedite the appropriate procedures after death. The document of gift, or a copy, may be deposited in any hospital,
procurement organization, or registry office that accepts it for safekeeping or for facilitation of procedures after death. On request of an interested person, upon or after the donor's death, the person in possession shall allow the interested person to examine or copy the document of gift.
(a) A health care provider or institution that intentionally violates this chapter is liable to the aggrieved individual or the individual's estate for damages of $10,000 or actual damages resulting from the violation, whichever is greater,
plus attorney fees as provided by court rule.
(b) A person who intentionally falsifies, forges, conceals, defaces, or obliterates an individual's advance health care directive or a revocation of an advance health care directive without the individual's consent, or who coerces or fraudulently induces an individual to give, revoke, or not to give an advance health care directive, is liable to that individual for damages of $10,000 or actual damages resulting from the action, whichever is greater, plus attorney fees as provided by court rule.
The coroner, the state medical examiner, or a local public health official may not release or permit the removal of a part from a body within that official's custody based on the fact that the official does not know of
(1) a refusal to make a gift;
(2) an indication by the decedent that is contrary to making a gift; or
(3) an objection to a gift by a person having priority to act under Section 13.52.180
(a).
Notwithstanding any other provision of this chapter, an agent or a surrogate may determine that life-sustaining procedures may be withheld or withdrawn from a patient with a qualifying condition when there is
(1) a durable power of attorney for health care or other writing that clearly expresses the patient's intent that the procedures be withheld or withdrawn; or
(2) no durable power of attorney for health care or other writing that clearly expresses the patient's intent to the contrary, the patient has a qualifying condition as determined under Section 13.52.160
, and withholding or withdrawing the procedures would be consistent with the patient's best interest.
(a) This chapter does not affect the right of an individual to make health care decisions while having capacity to make health care decisions.
(b) An individual is rebuttably presumed to have capacity to make a health care decision, to give or revoke an advance health care directive, and to designate or disqualify a surrogate.
(c) An individual who is a qualified patient, including an individual for whom a physician has issued a do not resuscitate order, has the right to make a decision regarding the use of cardiopulmonary resuscitation and other life-sustaining procedures as long as the individual is able to make the decision. If an individual who is a qualified patient,
including an individual for whom a physician has issued a do not resuscitate order, is not able to make the decision,
the protocol adopted under Section 13.52.065
for do not resuscitate orders governs a decision regarding the use of cardiopulmonary resuscitation and other life-sustaining procedures.
(a) Before implementing a health care decision for a woman of childbearing age that would affect a fetus if present, the supervising health care provider shall take reasonable steps to determine whether the woman is pregnant.
(b) Notwithstanding any other provision of this chapter to the contrary, an advance health care directive by a patient or a decision by the person then authorized to make health care decisions for a patient may not be given effect if
(1) the patient is a woman who is pregnant and lacks capacity;
(2) the directive or decision is to withhold or withdraw life-sustaining procedures;
(3) the withholding or withdrawal of the life-sustaining procedures would, in reasonable medical judgment, be likely to result in the death of the patient; and
(4) it is probable that the fetus could develop to the point of live birth if the life-sustaining procedures were provided.
(c) This section does not apply to emergency services in the field.
(a) The following persons may become donees of anatomical gifts for the purposes stated:
(1) a hospital, physician, surgeon, or procurement organization for transplantation, therapy, medical or dental education,
research, or advancement of medical or dental science;
(2) an accredited medical or dental school, college, or university for education, research, or advancement of medical or dental science; or
(3) a designated individual for transplantation or therapy needed by that individual.
(b) An anatomical gift may be made to a designated donee or without designating a donee. If a donee is not designated or if the donee is not available or rejects the anatomical gift, the anatomical gift may be accepted by any hospital.
(c) If the donee knows of the decedent's refusal or contrary indications to make an anatomical gift or that an anatomical gift by a member of a class having priority to act is opposed by a member of the same class or a prior class under Section
13.52.180
(a), the donee may not accept the anatomical gift.
(a) Rights of a donee created by an anatomical gift are superior to rights of others except with respect to autopsies under Section 13.52.260(b). A donee may accept or reject an anatomical gift. If a donee accepts an anatomical gift of an entire body, the donee, subject to the terms of the gift,
may allow embalming and use of the body in funeral services. If the gift is of a part of a body, the donee, upon the death of the donor and before embalming, shall cause the part to be removed without unnecessary mutilation. After removal of the part, custody of the remainder of the body vests in the person under obligation to dispose of the body.
(b) The time of death of a donor shall be determined by a physician or nurse under Section 09.68.120
. A physician who attends the donor at death and a physician who determines the time of death may not participate in the procedures for removing or transplanting a part unless the document of gift designates a particular physician under Section 13.52.170
(d).
(c) If there has been an anatomical gift, a technician may remove any donated parts after determination of death by a physician or nurse.
(a) An anatomical gift authorizes any reasonable examination necessary to assure medical acceptability of the gift for the purposes intended.
(b) The provisions of Section 13.52.170
- 13.52.280 are subject to the autopsy provisions of Section 12.65.
(c) A hospital, physician, surgeon, coroner, medical examiner, local public health officer, technician, or other person who acts in accordance with Section 13.52.170
- 13.52.280 or with the applicable anatomical gift law of another state or attempts in good faith to act in accordance with Section 13.52.170
- 13.52.280 or with the applicable anatomical gift law of another state is not liable for that act in a civil action or criminal proceeding.
(d) An individual who makes an anatomical gift under Section 13.52.170
or 13.52.180 and the individual's estate are not liable for any injury or damage that may result from the making or the use of the anatomical gift.
(a) An attending physician may issue a do not resuscitate order for a patient of the physician. The physician shall document the grounds for the order in the patient's medical file.
(b) The department shall by regulation adopt a protocol, subject to the approval of the State Medical Board, for do not resuscitate orders that sets out a standardized method of procedure for the withholding of cardiopulmonary resuscitation by health care providers and health care institutions.
(c) The department shall develop standardized designs and symbols for do not resuscitate identification cards, forms,
necklaces, and bracelets that signify, when carried or worn, that the carrier or wearer is an individual for whom a physician has issued a do not resuscitate order.
(d) A health care provider other than a physician shall comply with the protocol adopted under (b) of this section for do not resuscitate orders when the health care provider is presented with a do not resuscitate identification, an oral do not resuscitate order issued directly by a physician if the applicable hospital allows oral do not resuscitate orders,
or a written do not resuscitate order entered on and as required by a form prescribed by the department.
(e) Notwithstanding (d) of this section, if an individual has made an anatomical gift to occur at death and is in a hospital when a do not resuscitate order or an order to withdraw life-sustaining procedures is to be implemented for the individual, the order may not be implemented until the subject of the anatomical gift can be evaluated to determine if it is suitable for donation.
(f) A do not resuscitate order may not be made ineffective unless a physician revokes the do not resuscitate order. A request to revoke a do not resuscitate order may only be made by the person for whom the order is written or, if the person for whom the order is written is under 18 years of age, by the parent or guardian of the person.
(a) Any member of the following classes of persons, in the order of priority listed, may make an anatomical gift of all or a part of the decedent's body for an authorized purpose, unless the decedent, at the time of death, has made an unrevoked refusal to make that anatomical gift:
(1) the spouse of the decedent;
(2) an adult son or daughter of the decedent;
(3) either parent of the decedent;
(4) an adult brother or sister of the decedent;
(5) a grandparent of the decedent; and
(6) an agent or a surrogate of the decedent at the time of death.
(b) An anatomical gift may not be made by a person listed in (a) of this section if
(1) a person in a prior class is available at the time of death to make an anatomical gift;
(2) the person proposing to make an anatomical gift knows of a refusal or contrary indications by the decedent; or
(3) the person proposing to make an anatomical gift knows of an objection to making an anatomical gift by a member of the person's class or a prior class.
(c) An anatomical gift by a person authorized under (a) of this section shall be made by
(1) a document of gift signed by the person;
(2) the person's telegraphic, recorded telephonic, or other recorded message, or another form of communication from the person that is contemporaneously reduced to writing and signed by the recipient; or
(3) the person's agent or surrogate.
(d) An anatomical gift by a person authorized under (a) of this section may be revoked by any member of the same or a prior class if, before procedures have begun for the removal of a part from the body of the decedent, the physician,
surgeon, or technician removing the part knows of the revocation.
(a) If a health care provider or health care institution makes reasonable efforts, with a level of diligence appropriate to the seriousness and urgency of the situation, to ensure the validity of an advance health care directive or a person's assumption of authority to make health care decisions for a patient, a health care provider or institution acting in good faith and in accordance with generally accepted health care standards applicable to the health care provider or institution is not subject to civil or criminal liability or to discipline for unprofessional conduct for
(1) providing health care information in good faith under Section 13.52.070;
(2) complying with a health care decision of a person based on a reasonable belief that the person has authority to make a health care decision for a patient, including a decision to withhold or withdraw health care;
(3) declining to comply with a health care decision of a person based on a reasonable belief that the person then lacked authority;
(4) complying with an advance health care directive and reasonably assuming that the directive was valid when made and has not been revoked or terminated;
(5) participating in the withholding or withdrawal of cardiopulmonary resuscitation under the direction or with the authorization of a physician or upon discovery of do not resuscitate identification upon an individual;
(6) causing or participating in providing cardiopulmonary resuscitation or other life-sustaining procedures
(A) under Section 13.52.065
(e) when an individual has made an anatomical gift; or
(B) because an individual has made a do not resuscitate order ineffective under Section 13.52.065
(f) or another provision of this chapter; or
(7) acting in good faith under the terms of this chapter or the law of another state relating to anatomical gifts.
(b) An individual acting as an agent, a guardian, or a surrogate under this chapter is not subject to civil or criminal liability or to discipline for unprofessional conduct for health care decisions made in good faith.
(a) In the absence of evidence to the contrary of the patient's intent, this chapter establishes a presumption in favor of life, consistent with the best interest of the patient.
(b) Notwithstanding any other provision of law, death resulting from the withholding or withdrawal of cardiopulmonary resuscitation or other life-sustaining procedures does not, for any purpose, constitute a suicide or homicide if the withholding or withdrawal is
(1) consistent with this chapter; and
(2) from an individual
(A) for whom a do not resuscitate order has not been issued;
(B) for whom a do not resuscitate order has been issued under
(i) the protocol for do not resuscitate orders established under Section 13.52.065; or
(ii) a do not resuscitate identification found on the individual.
(c) The issuance of a do not resuscitate order under this chapter, the possession of do not resuscitate identification under this chapter, or the making of a health care directive under this chapter does not affect in any manner the sale,
procurement, or issuance of a policy of life insurance, and does not modify the terms of an existing policy of life insurance. A policy of life insurance is not legally impaired or invalidated in any manner by the withholding or withdrawal of life-sustaining procedures from an insured individual or the withholding or withdrawal of cardiopulmonary resuscitation from an individual who possesses do not resuscitate identification or for whom a do not resuscitate order has been issued, notwithstanding any term of the policy to the contrary.
(d) This chapter does not authorize mercy killing, assisted suicide, or euthanasia.
(e) This chapter does not authorize or require a health care provider or institution to provide health care contrary to generally accepted health care standards applicable to the health care provider or institution.
(f) This chapter does not authorize an agent or a surrogate to consent to the admission of an individual to a mental health facility unless the individual's written advance health care directive expressly so provides, and the period of admission may not exceed 17 days.
(g) This chapter does not affect other statutes of this state governing treatment for mental illness of an individual involuntarily committed to a mental health facility.
ANATOMICAL GIFT BY NEXT OF KIN,
GUARDIAN, AGENT, OR SURROGATE
Under Section 13.52.170
- 13.52.280, I make this anatomical gift from the
body of
____________________________________________________________________ (name of decedent)
who died on
____________________________________________________________________ (date)
at
____________________________________________________________________ (place) (city)
in
____________________________________________________________________ (state)
The marks in the appropriate squares and the words filled into the
blanks below indicate my relationship to the decedent and my wishes
respecting the gift.
I survive the decedent as ( ) spouse; ( ) adult son or daughter; ( ) parent; ( ) adult brother or sister; ( ) grandparent; or I am the decedent's ( ) agent under Section 13.52. I hereby give (check boxes applicable):
( ) any needed organs, tissues, or parts; ( ) the following organs, tissues, or parts only:
__________________________________________________________________ ;
( ) the following purposes only: __________________________________________________________________ . ____________________________________________________________________ (date) (signature of survivor)
(address of survivor) (a) Except in the case of mental illness under (c) of this section, a principal may revoke the designation of an agent only by a signed writing or by personally informing the supervising health care provider.
(b) Except in the case of mental illness under (c) of this section, a principal may revoke all or part of an advance health care directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke.
(c) In the case of mental illness, an advance health care directive may be revoked in whole or in part at any time by the principal if the principal does not lack capacity and is competent. A revocation is effective when a competent principal with capacity communicates the revocation to the attending physician or other health care provider. The attending physician or other health care provider shall note the revocation on the principal's medical record. In the case of mental illness, the authority of a named agent and an alternative agent named in the advance health care directive continues in effect as long as the advance health care directive appointing the agent is in effect or until the agent has withdrawn. For the purposes of this subsection, a principal is not considered competent when
(1) it is the opinion of the court in a guardianship proceeding under Section 13.26, the opinion of two physicians, at least one of whom is a psychiatrist, or the opinion of a physician and a professional mental health clinician, that the principal is not competent; or
(2) a court in a hearing under Section 47.30.735
, 47.30.750, or 47.30.770 determines that the principal is gravely disabled; in this paragraph, 'gravely disabled' has the meaning given in Section 47.30.915
(7)(B).
(d) A health care provider, agent, guardian, or surrogate who is informed of a revocation shall promptly communicate the fact of the revocation to the supervising health care provider and to any health care institution at which the patient is receiving care.
(e) A decree of annulment, divorce, dissolution of marriage, or legal separation revokes a previous designation of a spouse as agent unless otherwise specified in the decree or in a durable power of attorney for health care.
(f) An advance health care directive that conflicts with an earlier advance health care directive revokes the earlier directive to the extent of the conflict.
(a) If, at or near the time of death of a patient, there is no medical record that the patient has made or refused to make an anatomical gift, the hospital administrator or a designee of the hospital shall contact an organ procurement organization so that the organ procurement organization may discuss the potential to make a gift with the family,
agent, or surrogate of the patient. The organ procurement organization shall discuss the potential gift with reasonable discretion and sensitivity to the circumstances of the family.
(b) Notwithstanding (a) of this section, a hospital administrator or other designee of the hospital is not required to contact an organ procurement organization if the gift is not suitable, based on accepted medical standards, for a purpose specified in Section 13.52.210
.
(c) An entry shall be made in the medical record of the patient, stating the name and affiliation of the individual from the organ procurement organization who discusses the potential gift with the family, agent, or surrogate under (a) of this section, and the relationship to the patient of the family member, agent, or surrogate with whom the potential gift was discussed.
(d) The following persons shall make a reasonable search for a document of gift or other information identifying the bearer as a donor or as an individual who has refused to make an anatomical gift:
(1) a law enforcement officer, fire fighter, paramedic, or other emergency rescuer finding an individual who the searcher believes is dead or near death; and
(2) a hospital or an organ procurement organization, upon the admission of an individual at or near the time of death, if there is not immediately available any other source of that information.
(e) If a document of gift or evidence of refusal to make an anatomical gift is located by the search required by (d)(1) of this section, and the individual or body to whom it relates is taken to a hospital, the hospital must be notified of the contents, and the document or other evidence must be sent to the hospital.
(f) If, at or near the time of death of a patient, a hospital knows that an anatomical gift has been made under Section 13.52.170
or 13.52.180(a), or that a patient or an individual identified as in transit to the hospital is a donor, the hospital shall notify an organ procurement organization. The hospital shall cooperate in the implementation of the anatomical gift or release and removal of a part.
(g) Notwithstanding Section 13.52.090
, a person who fails to discharge the duties imposed by this section is not subject to criminal or civil liability but is subject to appropriate administrative sanctions.
(h) The commissioner of health and social services shall adopt regulations to implement (a) - (c) of this section.
(a) An individual who is at least 18 years of age may
(1) make an anatomical gift for any of the purposes stated in Section 13.52.210(a);
(2) limit an anatomical gift to one or more of those purposes; or
(3) refuse to make an anatomical gift.
(b) An anatomical gift may be made only by a document of gift signed by the donor. If the donor cannot sign, the document of gift shall be signed by another individual and by two witnesses, all of whom have signed at the direction and in the presence of the donor and of each other, and state that it has been signed at the direction and in the presence of the donor and of each other.
(c) If a document of gift is attached to or imprinted on a donor's motor vehicle driver's license, revocation, suspension,
expiration, or cancellation of the license does not invalidate the anatomical gift.
(d) A document of gift may designate a particular physician or surgeon to carry out the appropriate procedures. In the absence of a designation or if the designee is not available, the donee or other person authorized to accept the anatomical gift may employ or authorize any physician, surgeon, or technician to carry out the appropriate procedures.
(e) An anatomical gift by will takes effect upon death of the testator, whether or not the will is probated. If, after death, the will is declared invalid for testamentary purposes, the validity of the anatomical gift is unaffected.
(f) Notwithstanding Section 13.52.020
, a donor may amend or revoke an anatomical gift, not made by will, only by
(1) a signed statement;
(2) an oral statement made in the presence of two individuals;
(3) any form of communication during a terminal illness or injury addressed to a physician or surgeon; or
(4) the delivery of a signed statement to a specified donee to whom a document of gift had been delivered.
(g) Notwithstanding Section 13.52.020
, the donor of an anatomical gift made by will may amend or revoke the gift in the manner provided for amendment or revocation of wills, or as provided in (f) of this section.
(h) An anatomical gift that is not revoked by the donor before death is irrevocable and does not require the consent or concurrence of any person after the donor's death.
(i) An individual may refuse to make an anatomical gift of the individual's body or part by
(1) a writing signed in the same manner as a document of gift;
(2) a statement attached to or imprinted on a donor's motor vehicle operator's or chauffeur's license;
(3) any other writing used to identify the individual as refusing to make an anatomical gift;
(4) during a terminal illness or injury, an oral statement or other form of communication.
(a) Except as provided in Section 13.52.170
(a), an adult may give an individual instruction. Except as provided in Section 13.52.170
(b), the instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.
(b) An adult may execute a durable power of attorney for health care, which may authorize the agent to make any health care decision the principal could have made while having capacity. The power remains in effect notwithstanding the principal's later incapacity and may include individual instructions. The power must be in writing, contain the date of its execution, be signed by the principal, and be witnessed by one of the following methods:
(1) signed by at least two individuals who are personally known by the principal, each of whom witnessed either the signing of the instrument by the principal or the principal's acknowledgment of the signature of the instrument; or
(2) acknowledged before a notary public at a place in this state.
(c) Unless related to the principal by blood, marriage, or adoption, an agent under a durable power of attorney for health care may not be an owner, operator, or employee of the health care institution at which the principal is receiving care.
(d) A witness for a durable power of attorney for health care may not be
(1) a health care provider employed at the health care institution or health care facility where the principal is receiving health care;
(2) an employee of the health care provider providing health care to the principal, or of the health care institution or health care facility where the principal is receiving health care; or
(3) the agent.
(e) At least one of the individuals used as a witness for a durable power of attorney for health care shall be someone who is not
(1) related to the principal by blood, marriage, or adoption; or
(2) entitled to a portion of the estate of the principal upon the principal's death under a will or codicil of the principal existing at the time of execution of the durable power of attorney for health care or by operation of law then existing.
(f) Unless otherwise specified in the durable power of attorney for health care, the authority of an agent becomes effective only upon a determination that the principal lacks capacity and ceases to be effective upon a determination that the principal has recovered capacity.
(g) Unless otherwise specified in a written advance health care directive, a determination that a principal lacks or has recovered capacity, or that another condition exists that affects an individual instruction or the authority of an agent, shall be made by
(1) the primary physician, except in the case of mental illness;
(2) a court in the case of mental illness, unless the situation is an emergency; or
(3) the primary physician or another health care provider in the case of mental illness where the situation is an emergency.
(h) An agent shall make a health care decision in accordance with the principal's individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the agent's determination of the principal's best interest. In determining the principal's best interest, the agent shall consider the principal's personal values to the extent known to the agent.
(i) A health care decision made by an agent for a principal is effective without judicial approval.
(j) A written advance health care directive may include the individual's nomination of a guardian of the individual.
(k) An advance health care directive, including an advance health care directive that is made in compliance with the laws of another state, is valid for purposes of this chapter to the extent that it complies with the laws of this state. (a) Before implementing a health care decision made for a patient, a supervising health care provider, if possible, shall promptly communicate to the patient the decision made and the identity of the person making the decision.
(b) Except as provided in Section 13.52.200
, a supervising health care provider who knows of the existence of an advance health care directive, a revocation of an advance health care directive, or a designation or disqualification of a surrogate shall promptly record its existence in the patient's health care record, shall request a copy if it is in writing, and shall arrange for its maintenance in the health care record if a copy is furnished.
(c) A supervising health care provider who makes or is informed of a determination that a patient lacks or has recovered capacity, or that another condition exists that affects an individual instruction or the authority of an agent, a guardian, or a surrogate, shall promptly record the determination in the patient's health care record and communicate the determination to the patient, if possible, and to any person then authorized to make health care decisions for the patient.
(d) Except as provided in (e) and (f) of this section, a health care provider, health care institution, or health care facility providing care to a patient shall comply with
(1) an individual instruction of the patient and with a reasonable interpretation of that instruction made by a person then authorized to make health care decisions for the patient; and
(2) a health care decision for the patient made by a person then authorized to make health care decisions for the patient to the same extent as if the decision had been made by the patient while having capacity.
(e) A health care provider may decline to comply with an individual instruction or a health care decision for reasons of conscience, except for a do not resuscitate order. A health care institution or health care facility may decline to comply with an individual instruction or health care decision if the instruction or decision is contrary to a policy of the institution or facility that is expressly based on reasons of conscience and if the policy was timely communicated to the patient or to a person then authorized to make health care decisions for the patient.
(f) A health care provider, health care institution, or health care facility may decline to comply with an individual instruction or a health care decision that requires medically ineffective health care or health care contrary to generally accepted health care standards applicable to the provider, institution, or facility. In this subsection,
'medically ineffective health care' means health care that according to reasonable medical judgment cannot cure the patient's illness, cannot diminish its progressive course, and cannot effectively alleviate severe discomfort and distress.
(g) A health care provider, health care institution, or health care facility that declines to comply with an individual instruction or a health care decision shall
(1) promptly inform the patient, if possible, and any person then authorized to make health care decisions for the patient that the provider, institution, or facility has declined to comply with the instruction or decision;
(2) provide continuing care to the patient until a transfer is effected; and
(3) unless the patient or person then authorized to make health care decisions for the patient refuses assistance,
immediately cooperate and comply with a decision by the patient or a person then authorized to make health care decisions for the patient to transfer the patient to another health care institution, to another health care facility,
to the patient's home, or to another location chosen by the patient or by the person then authorized to make health care decisions for the patient.
(h) Except as provided for civil commitments under Section 47.30.817
, a health care provider, health care institution, or health care facility may not require or prohibit the execution or revocation of an advance health care directive as a condition for providing health care.
(a) Except in the case of mental health treatment and except as provided by Section 13.52.180
(a) and (b), a surrogate may make a health care decision for a patient who is an adult if an agent or guardian has not been appointed or the agent or guardian is not reasonably available, and if the patient has been determined by the primary physician to lack capacity.
(b) Subject to Section 13.52.055
(b), a surrogate may make a decision regarding mental health treatment for a patient who is an adult if
(1) an agent or guardian has not been appointed or the agent or guardian is not reasonably available;
(2) the mental health treatment is needed on an emergency basis; and
(3) the patient has been determined to lack capacity by
(A) two physicians, one of whom is a psychiatrist; or
(B) a physician and a professional mental health clinician.
(c) Except as provided for anatomical gifts in Section 13.52.170
(b), an adult may designate an individual to act as surrogate for that adult by personally informing the supervising health care provider. Except as provided by Section 13.52.180
(a) and (b), in the absence of a designation, or if the designee is not reasonably available, a member of the following classes of the patient's family who is reasonably available, in descending order of priority, may act as surrogate:
(1) the spouse, unless legally separated;
(2) an adult child;
(3) a parent; or
(4) an adult sibling.
(d) Except as provided by (l) of this section or Section 13.52.180(a) or (b), if none of the individuals eligible to act as surrogate under (c) of this section is reasonably available, an adult who has exhibited special care and concern for the patient, who is familiar with the patient's personal values, and who is reasonably available may act as surrogate.
(e) A surrogate shall communicate the surrogate's assumption of authority as promptly as practicable to the health care provider, the health care institution, and the members of the patient's family specified in (c) of this section who can be readily contacted.
(f) If more than one member of a class under (c)(2) - (4) of this section assumes authority to act as surrogate, the members of that class do not agree on a health care decision, and the supervising health care provider is informed of the disagreement, the supervising health care provider shall comply with the decision of a majority of the members of that class who have communicated their views to the provider. If the class is evenly divided concerning the health care decision and the supervising health care provider is informed of the even division, that class and all individuals having a lower priority under (c)(2) - (4) of this section are disqualified from making the decision, and the primary physician, after consulting with all individuals in that evenly divided class who are reasonably available, shall make a decision based on the consultation and the primary physician's own determination of the best interest of the patient.
(g) A surrogate shall make a health care decision in accordance with the patient's individual instructions or other advance health care directives, if any, and other wishes to the extent known to the surrogate. Otherwise, the surrogate shall make the decision in accordance with the surrogate's determination of the patient's best interest. In determining the patient's best interest, the surrogate shall consider the patient's personal values to the extent known to the surrogate.
(h) If a patient's primary health care provider observes that a surrogate is not abiding by the wishes, values, and best interest of the patient, the primary health care provider may decline to comply with a decision of the surrogate and shall notify the health care institution where the primary health care provider is providing health care to the patient.
(i) A health care decision made by a surrogate for a patient is effective without judicial approval.
(j) A patient who has capacity may, at any time, disqualify another person, including a member of the patient's family,
from acting as the patient's surrogate by a signed writing or by personally informing the supervising health care provider of the disqualification.
(k) Unless related to the patient by blood, marriage, or adoption, a surrogate may not be an owner, operator, or employee of the health care facility where the patient is receiving care.
(l) A supervising health care provider may require an individual claiming the right to act as a surrogate for a patient to provide a written declaration under penalty of perjury stating facts and circumstances reasonably sufficient to establish the claimed authority.
In this chapter, unless the context otherwise requires,
(1) 'advance health care directive' means an individual instruction or a durable power of attorney for health care;
(2) 'agent' means an individual designated in a durable power of attorney for health care to make a health care decision for the individual granting the power;
(3) 'anatomical gift' means an individual instruction that makes a donation of all or a part of an individual's body to take effect upon or after death;
(4) 'artificial nutrition and hydration' means medically appropriate nutrition and hydration delivered
(A) through an intravenous needle placed directly in a vein; or
(B) by a tube that is inserted into a functioning gastrointestinal tract;
(5) 'available' means, when referring to a person, that the
(A) person's existence is known;
(B) person can be contacted;
(C) person does not lack capacity;
(D) person does not refuse to accept the position; and
(E) person is willing to make a health care decision;
(6) 'best interest' means that the benefits to the individual resulting from a treatment outweigh the burdens to the individual resulting from that treatment after assessing
(A) the effect of the treatment on the physical, emotional, and cognitive functions of the patient;
(B) the degree of physical pain or discomfort caused to the individual by the treatment or the withholding or withdrawal of the treatment;
(C) the degree to which the individual's medical condition, the treatment, or the withholding or withdrawal of treatment results in a severe and continuing impairment;
(D) the effect of the treatment on the life expectancy of the patient;
(E) the prognosis of the patient for recovery, with and without the treatment;
(F) the risks, side effects, and benefits of the treatment or the withholding of treatment; and
(G) the religious beliefs and basic values of the individual receiving treatment, to the extent that these may assist the decision-maker to determine benefits and burdens;
(7) 'capacity,' except in (9) of this section, means an individual's ability to receive and evaluate information effectively or communicate decisions to the extent necessary to make mental health treatment decisions;
(8) 'cardiopulmonary resuscitation' means an attempt to restore spontaneous circulation;
(9) 'competent' means that an individual has the capacity
(A) to assimilate relevant facts and to appreciate and understand the individual's situation with regard to those facts;
and
(B) to participate in treatment decisions by means of a rational thought process;
(10) 'decedent' means a deceased individual or infant, but does not include a dead or stillborn fetus;
(11) 'department' means the Department of Health and Social Services;
(12) 'document of gift' means a card, a statement attached to or imprinted on a driver's license, a will, an advance health care directive under Section 13.52.300
, or another writing used to make an anatomical gift;
(13) 'donor' means an individual who makes an anatomical gift;
(14) 'do not resuscitate identification' means an identification card, form, necklace, or bracelet that carries the standardized design or symbol developed by the department under Section 13.52.065
to signify, when carried or worn, that the carrier or wearer is an individual for whom a physician has issued a do not resuscitate order;
(15) 'do not resuscitate order' means a directive from a licensed physician that emergency cardiopulmonary resuscitation should not be administered to a qualified patient;
(16) 'durable power of attorney for health care' means a power of attorney that remains in effect when the principal lacks capacity; in this paragraph, 'power of attorney' means the designation of an agent to make health care decisions for the individual granting the power;
(17) 'generally accepted health care standards' includes the protocol for do not resuscitate orders that is adopted under Section 13.52.065
;
(18) 'guardian' means a judicially appointed person having authority to make a health care decision for an individual;
(19) 'health care' means any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect an individual's physical or mental condition;
(20) 'health care decision' means a decision made by an individual or the individual's agent, guardian, or surrogate regarding the individual's health care, including
(A) selection and discharge of health care providers and institutions;
(B) approval or disapproval of proposed diagnostic tests, surgical procedures, and programs of medication;
(C) direction to provide, withhold, or withdraw artificial nutrition and hydration if providing, withholding, or withdrawing artificial nutrition, artificial hydration, or artificial nutrition and hydration is in accord with generally accepted health care standards applicable to health care providers or institutions;
(D) the administration or withdrawal of psychotropic medications, the use of electroconvulsive treatment, and the admission to a mental health facility; and
(E) making an anatomical gift at death;
(21) 'health care facility' means a nursing home, a rehabilitation center, a long-term care facility, and any other health care institution that administers health care and that provides overnight stays in the ordinary course of the facility's business;
(22) 'health care institution' means an institution, facility, or agency licensed, certified, or otherwise authorized or permitted by law to provide health care in the ordinary course of business;
(23) 'health care provider' means an individual licensed, certified, or otherwise authorized or permitted by law to provide health care in the ordinary course of business or practice of a profession;
(24) 'hospital' means a facility
(A) licensed, accredited, or approved as a hospital under the laws of this state; or
(B) operated as a hospital by the United States government, this state, or a subdivision of this state;
(25) 'individual instruction' means an individual's direction concerning a health care decision for the individual;
(26) 'life-sustaining procedures' means any medical treatment, procedure, or intervention that, in the judgment of the primary physician, when applied to a patient with a qualifying condition, would not be effective to remove the qualifying condition, would serve only to prolong the dying process, or, when administered to a patient with a condition of permanent unconsciousness, may keep the patient alive but is not expected to restore consciousness; in this paragraph, 'medical treatment, procedure, or intervention' includes assisted ventilation, renal dialysis, surgical procedures, blood transfusions, and the administration of drugs, including antibiotics, or artificial nutrition and hydration;
(27) 'mental health facility' has the meaning given to 'designated treatment facility' in Section 47.30.915
;
(28) 'mental health treatment' means electroconvulsive treatment, treatment with psychotropic medication, or admission to and retention in a health care institution for mental health treatment;
(29) 'organ procurement organization' means an organization that has been designated by the United States Department of Health and Human Services to coordinate activities for the procurement of body parts for any portion of this state;
(30) 'part' means an organ, tissue, an eye, a bone, an artery, blood, fluid, or another portion of a human body, except fetal tissue;
(31) 'permanent unconsciousness' means a condition
(A) that, to a high degree of medical certainty, will last permanently without improvement;
(B) in which, to a high degree of medical certainty, thought, sensation, purposeful action, social interaction, and awareness of self and the environment are absent; and
(C) for which, to a high degree of medical certainty, initiating or continuing life-sustaining procedures, in light of the patient's medical outcome, provides only minimal medical benefit;
(32) 'person' means an individual, corporation, business trust, estate, trust, partnership, joint venture, association,
government, governmental subdivision, governmental agency, or another legal or commercial entity;
(33) 'physician' or 'surgeon' means an individual licensed or otherwise authorized to practice medicine and surgery or osteopathy and surgery under the laws of any state;
(34) 'primary physician' means a physician designated by an individual, or by the individual's agent, guardian, or surrogate, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility;
(35) 'qualified patient' means a patient with a qualifying condition who is eligible for do not resuscitate identification;
(36) 'qualifying condition' means a terminal condition or permanent unconsciousness in a patient;
(37) 'reasonably available' means available using a level of diligence appropriate to the seriousness and urgency of an individual's health care needs;
(38) 'state' means a state, territory, or possession of the United States, the District of Columbia, or the Commonwealth of Puerto Rico;
(39) 'supervising health care provider' means the primary physician or the physician's designee, or the health care provider or the provider's designee who has undertaken primary responsibility for an individual's health care;
(40) 'surrogate' means an individual, other than a patient's agent or guardian, authorized under this chapter to make a health care decision for the patient;
(41) 'technician' means an individual who is licensed or certified by the State Medical Board to remove or process a part;
(42) 'terminal condition' means an incurable or irreversible illness or injury
(A) that without administration of life-sustaining procedures will result in death in a short period of time;
(B) for which there is no reasonable prospect of cure or recovery;
(C) that imposes severe pain or otherwise imposes an inhumane burden on the patient; and
(D) for which, in light of the patient's medical condition, initiating or continuing life-sustaining procedures will provide only minimal medical benefit.
The following sample form may be used to create an advance health care directive. The other sections of this chapter govern the effect of this or any other writing used to create an advance health care directive. This form may be duplicated. This form may be modified to suit the needs of the person, or a different form that complies with this chapter may be used, including the mandatory witnessing requirements:
ADVANCE HEALTH CARE DIRECTIVE
Explanation
You have the right to give instructions about your own health care to
the extent allowed by law. You also have the right to name someone else
to make health care decisions for you to the extent allowed by law.
This form lets you do either or both of these things. It also lets you
express your wishes regarding the designation of your health care
provider. If you use this form, you may complete or modify all or any
part of it. You are free to use a different form if the form complies
with the requirements of Section 13.52.
Part 1 of this form is a durable power of attorney for health care. A
'durable power of attorney for health care' means the designation of an
agent to make health care decisions for you. Part 1 lets you name
another individual as an agent to make health care decisions for you if
you do not have the capacity to make your own decisions or if you want
someone else to make those decisions for you now even though you still
have the capacity to make those decisions. You may name an alternate
agent to act for you if your first choice is not willing, able, or
reasonably available to make decisions for you. Unless related to you,
your agent may not be an owner, operator, or employee of a health care
institution where you are receiving care.
Unless the form you sign limits the authority of your agent, your agent
may make all health care decisions for you that you could legally make
for yourself. This form has a place for you to limit the authority of
your agent. You do not have to limit the authority of your agent if you
wish to rely on your agent for all health care decisions that may have
to be made. If you choose not to limit the authority of your agent,
your agent will have the right, to the extent allowed by law, to
(a) consent or refuse consent to any care, treatment, service, or
procedure to maintain, diagnose, or otherwise affect a physical or
mental condition, including the administration or discontinuation of
psychotropic medication;
(b) select or discharge health care providers and institutions;
(c) approve or disapprove proposed diagnostic tests, surgical
procedures, and programs of medication;
(d) direct the provision, withholding, or withdrawal of artificial
nutrition and hydration and all other forms of health care; and
(e) make an anatomical gift following your death.
Part 2 of this form lets you give specific instructions for any aspect
of your health care to the extent allowed by law, except you may not
authorize mercy killing, assisted suicide, or euthanasia. Choices are
provided for you to express your wishes regarding the provision,
withholding, or withdrawal of treatment to keep you alive, including
the provision of artificial nutrition and hydration, as well as the
provision of pain relief medication. Space is provided for you to add
to the choices you have made or for you to write out any additional
wishes.
Part 3 of this form lets you express an intention to make an anatomical
gift following your death.
Part 4 of this form lets you make decisions in advance about certain
types of mental health treatment.
Part 5 of this form lets you designate a physician to have primary
responsibility for your health care.
After completing this form, sign and date the form at the end and have
the form witnessed by one of the two alternative methods listed below.
Give a copy of the signed and completed form to your physician, to any
other health care providers you may have, to any health care
institution at which you are receiving care, and to any health care
agents you have named. You should talk to the person you have named as
your agent to make sure that the person understands your wishes and is
willing to take the responsibility.
You have the right to revoke this advance health care directive or
replace this form at any time, except that you may not revoke this
declaration when you are determined not to be competent by a court, by
two physicians, at least one of whom shall be a psychiatrist, or by
both a physician and a professional mental health clinician. In this
advance health care directive, 'competent' means that you have the
capacity
(1) to assimilate relevant facts and to appreciate and understand
your situation with regard to those facts; and
(2) to participate in treatment decisions by means of a rational
thought process.
PART 1
DURABLE POWER OF ATTORNEY FOR
HEALTH CARE DECISIONS
(1) DESIGNATION OF AGENT. I designate the following individual as my
agent to make health care decisions for me:
______________________________________________________________________ (name of individual you choose as agent)
______________________________________________________________________ (address) (city) (state) (zip code)
______________________________________________________________________ (home telephone) (work telephone)
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)
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 to the extent known to
the agent in making all health care decisions for me. If these are not
known, my agent is authorized to make these decisions in accordance
with my best interest, including decisions to provide, withhold, or
withdraw artificial hydration and nutrition and other forms of health
care to keep me alive, except as I state here:
_____________________________________________________________________ _____________________________________________________________________ _____________________________________________________________________ (Add additional sheets if needed.)
Under this authority, 'best interest' means that the benefits to you
resulting from a treatment outweigh the burdens to you resulting from
that treatment after assessing
(A) the effect of the treatment on your physical, emotional, and
cognitive functions;
(B) the degree of physical pain or discomfort caused to you by the
treatment or the withholding or withdrawal of the treatment;
(C) the degree to which your medical condition, the treatment, or
the withholding or withdrawal of treatment, results in a severe and
continuing impairment;
(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.)
(A) ‡ ñ 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) ‡ ñ 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)
‡ ñ (i) 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
‡ ñ (ii) 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;
‡ ñ Additional instructions: _________________________________________
__________________________________________________________________ (C) Artificial Nutrition and Hydration. If I am unable to safely
take nutrition, fluids, or nutrition and fluids (check your choices or
write your instructions),
‡ ñ I wish to receive artificial nutrition and hydration indefinitely;
‡ ñ I wish to receive artificial nutrition and hydration indefinitely,
unless it clearly increases my suffering and is no longer in my best
interest;
‡ ñ I wish to receive artificial nutrition and hydration on a limited
trial basis to see if I can improve;
‡ ñ In accordance with my choices in (6)(B) above, I do not wish to
receive artificial nutrition and hydration.
‡ ñ Other instructions: _____________________________________________
_____________________________________________________________________ (D) Relief from Pain.
‡ ñ I direct that adequate treatment be provided at all times for the
sole purpose of the alleviation of pain or discomfort; or
‡ ñ I give these instructions: ______________________________________
_____________________________________________________________________ (E) Should I become unconscious and I am pregnant, I direct that
_____________________________________________________________________ _____________________________________________________________________ (7) OTHER WISHES. (If you do not agree with any of the optional
choices above and wish to write your own, or if you wish to add to the
instructions you have given above, you may do so here.) I direct that
_____________________________________________________________________
_____________________________________________________________________ Conditions or limitations:
__________________________________________
____________________________________________________________________.
(Add additional sheets if needed.)
PART 3
(OPTIONAL)
ANATOMICAL GIFT AT DEATH
If you are satisfied to allow your agent to determine whether to make
an anatomical gift at your death, you do not need to fill out this
part of the form.
(8) Upon my death: (mark applicable box)
(A) ‡ ñ I give any needed organs, tissues, or other body parts, OR
(B) ‡ ñ I give the following organs, tissues, or other body parts
only ________________________________________________________________
(C) ‡ ñ My gift is for the following purposes (mark any of the
following you want):
‡ ñ (i) transplant;
‡ ñ (ii) therapy;
‡ ñ (iii) research;
‡ ñ (iv) education.
(D) ‡ ñ I refuse to make an anatomical gift.
PART 4
MENTAL HEALTH TREATMENT
This part of the declaration allows you to make decisions in advance
about mental health treatment. The instructions that you include in
this declaration will be followed only if a court, two physicians that
include a psychiatrist, or a physician and a professional mental health
clinician believe that you are not competent and cannot make treatment
decisions. Otherwise, you will be considered to be competent and to
have the capacity to give or withhold consent for the treatments.
If you are satisfied to allow your agent to determine what is best for
you in making these mental health 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.
(9) PSYCHOTROPIC MEDICATIONS. If I do not have the capacity to give
or withhold informed consent for mental health treatment, my wishes
regarding psychotropic medications are as follows:
________ I consent to the administration of the following medications:
_____________________________________________________________ ________ I do not consent to the administration of the following
medications: _________________________________________________________
Conditions or limitations: ___________________________________________
_____________________________________________________________________.
(10) ELECTROCONVULSIVE TREATMENT. If I do not have the capacity to
give or withhold informed consent for mental health treatment, my
wishes regarding electroconvulsive treatment are as follows:
________ I consent to the administration of electroconvulsive
treatment.
________ I do not consent to the administration of electroconvulsive
treatment.
Conditions or limitations: ___________________________________________
_____________________________________________________________________.
(11) ADMISSION TO AND RETENTION IN FACILITY. If I do not have the
capacity to give or withhold informed consent for mental health
treatment, my wishes regarding admission to and retention in a mental
health facility for mental health treatment are as follows:
________ I consent to being admitted to a mental health facility for
mental health treatment for up to ________ days. (The number of days
not to exceed 17.)
________ I do not consent to being admitted to a mental health facility
for mental health treatment.
Conditions or limitations: ___________________________________________
_____________________________________________________________________.
OTHER WISHES OR INSTRUCTIONS
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________ Conditions or limitations:
___________________________________________
_____________________________________________________________________.
PART 5
PRIMARY PHYSICIAN
(OPTIONAL)
(12) I designate the following physician as my primary physician:
____________________________________________________________________ (name of physician)
____________________________________________________________________ (address) (city) (state) (zip code)
____________________________________________________________________ (telephone)
OPTIONAL: If the physician I have designated above is not willing,
able, or reasonably available to act as my primary physician, I
designate the following physician as my primary physician:
____________________________________________________________________ (name of physician)
____________________________________________________________________ (address) (city) (state) (zip code)
____________________________________________________________________ (telephone)
(13) EFFECT OF COPY. A copy of this form has the same effect as the
original.
(14) SIGNATURES. Sign and date the form here:
______________________________________________________________________ (date) (sign your name)
______________________________________________________________________ (print your name)
______________________________________________________________________ (address) (city) (state) (zip code)
(15) WITNESSES. This advance care health directive will not be valid
for making health care decisions unless it is
(A) signed by two qualified adult witnesses who are personally
known to you and who are present when you sign or acknowledge your
signature; the witnesses may not be a health care provider employed at
the health care institution or health care facility where you are
receiving health care, an employee of the health care provider who is
providing health care to you, an employee of the health care
institution or health care facility where you are receiving health
care, or the person appointed as your agent by this document; at least
one of the two witnesses may not be related to you by blood, marriage,
or adoption or entitled to a portion of your estate upon your death
under your will or codicil; or
(B) acknowledged before a notary public in the state.
ALTERNATIVE NO. 1
Witness Who is Not Related to or a Devisee of the Principal
I swear under penalty of perjury under Section 11.56.200
that the principal
is personally known to me, that the principal signed or acknowledged
this durable power of attorney for health care in my presence, that the
principal appears to be of sound mind and under no duress, fraud, or
undue influence, and that I am not
(1) a health care provider employed at the health care institution
or health care facility where the principal is receiving health care;
(2) an employee of the health care provider providing health care to
the principal;
(3) an employee of the health care institution or health care
facility where the principal is receiving health care;
(4) the person appointed as agent by this document;
(5) related to the principal by blood, marriage, or adoption; or
(6) entitled to a portion of the principal's estate upon the
principal's death under a will or codicil.
______________________________________________________________________ (date) (signature of witness)
______________________________________________________________________ (printed name of witness)
______________________________________________________________________ (address) (city) (state) (zip code)
Witness Who May be Related to or a Devisee of the Principal
I swear under penalty of perjury under Section 11.56.200
that the principal
is personally known to me, that the principal signed or acknowledged
this durable power of attorney for health care in my presence, that the
principal appears to be of sound mind and under no duress, fraud, or
undue influence, and that I am not
(1) a health care provider employed at the health care institution
or health care facility where the principal is receiving health care;
(2) an employee of the health care provider who is providing health
care to the principal;
(3) an employee of the health care institution or health care
facility where the principal is receiving health care; or
(4) the person appointed as agent by this document.
_____________________________________________________________________ (date) (signature of witness)
_____________________________________________________________________ (printed name of witness)
_____________________________________________________________________ (address) (city) (state) (zip code)
ALTERNATIVE NO. 2
State of Alaska
________ Judicial District
On this ________ day of __________, in the year ________, before me,
_____________________________________ (insert name of notary public) appeared ________________________ , personally
known to me (or proved to me on the basis of satisfactory evidence) to
be the person whose name is subscribed to this instrument, and
acknowledged that the person executed it.
Notary Seal
____________________________ (signature of notary public)
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