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Advance Directive for Health Care
(Living Will and Health Care Proxy)

I understand that this document, my Advance Directive for Health Care, will be used to make my wishes known about what medical treatment or other care I would or would not want if become too sick to speak for myself.

I understand that I am not required to have an Advance Directive.

I understand that I can change my mind about these directions by tearing up this document and

  1. writing a new one, or
  2. telling someone at least 19 years of age of my wishes and asking him or her to write them down.

After I have executed my Advance Directive, I will tell my doctor, family and friends that I have an Advance Directive and where I will be keeping it.


SECTION 1. LIVING WILL

I, _________________________, being of sound mind and at least 19 years old, would like to make the following wishes known. I direct that my family, my doctors and health care workers, and all others follow the directions I have put in this Advance Directive.

I understand that these directions will only be used if I am not able to speak for myself.

Definitions:

For the purposes of this document, the following definitions apply:

  1. "Terminally Ill or Injured" means that my doctor and another doctor have decided that I have a condition that cannot be cured and that I will likely die in the near future from this condition.
  2. "Life Sustaining Treatment" includes drugs, machines, or medical procedures that would keep me alive but would not cure me. I know that even if I choose not to have life sustaining treatment, I will still get medicines and treatments that ease my pain and keep me comfortable unless otherwise directed.
  3. "Artificially provided food and hydration" means being given nutrients (food) and water through a tube or an IV to keep me alive if I can no longer chew or swallow on my own or with someone helping me.
  4. "Permanent unconsciousness" is when my doctor and another doctor agree that, within a reasonable degree of medical certainty, I can no longer think, feel anything, knowingly move, or be aware of being alive. They believe this condition will last indefinitely without hope for improvement and have watched me long enough to make that decision. At least one of these doctors must be qualified to make such a diagnosis.

IF I BECOME TERMINALLY ILL OR INJURED:

  • I DO want to have life sustaining treatment if I am terminally ill or injured.   _____ (my initials)
  • I DO want to have artificially provided food and hydration if I am terminally ill or injured.   _____ (my initials)

IF I BECOME PERMANENTLY UNCONSCIOUS:

  • I DO want to have life sustaining treatment if I become permanently unconscious.   _____ (my initials)
  • I DO want to have artificially provided food and hydration if I become permanently unconscious.   _____( my initials)

OTHER DIRECTIONS
The above are all my directions. I have no further directions. _____ (my initials)


SECTION 2. IF I NEED SOMEONE TO SPEAK FOR ME

I understand that I may use this document to name a person I would like to make medical or other decisions for me if I become too sick to speak for myself. I understand that such a person is called a health care proxy.

I know that I do not have to name a health care proxy, and that the directions in my Advance Directive for Health Care will be followed even if I do not name a health care proxy.

I want ____________________ to be my health care proxy. I have spoken with ____________________ about my wishes. ____________________ is my _______________________. ____________________'s contact information is:
____________________
____________________,  in Alabama, ____________________
Phone number: ____________________

If ____________________ is not able, not willing, or not available to be my health care proxy, _______________________ is my next choice. _______________________ is my _______________________. _______________________'s contact information is:
_______________________
_______________________, in Alabama, __________
Phone number: ______________________________

I DO want my health care proxy to make decisions about whether I am given food and water through a tube or an IV. _____ (my initials)

I understand that I can instruct my health care proxy:

  1. to follow only my directions as they are listed in this document, or
  2. to follow my directions as they are listed in this document, and to make any decisions about things I have not covered in this document, or
  3. to make the final decision, even though it could mean doing something different from what I have listed in this document.

I have considered the options available to me as listed above and I have decided to reject choices 2 and 3 in favour of choice 1. I want my health care proxy to  follow only the directions listed on this form.  _____ (my initials)

In accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), I authorize my health care proxy to review and receive any information regarding my physical or mental health, including medical and hospital records.


SECTION 3. THE THINGS LISTED IN THIS DOCUMENT ARE WHAT I WANT

I understand the following:

  • I understand that more options are available to me with respect to my future health care than those that are articulated in this document, and I confirm that the directions I have given were decided upon after much careful consideration in full awareness of the other options.  _______ (my initials)
  • If my doctor or hospital does not want to follow the directions I have listed, they must see that I get to a doctor or hospital who will follow my instructions.
  • If I am pregnant, or if I become pregnant, the choices I have made in this document will not be followed until after the birth.

EFFECT OF COPY
A copy of this Living Will Declaration has the same effect as the original.

The remainder of this document will be available when you have purchased a license.


Related documents

  • Power of Attorney: grant someone authority to act on your behalf regarding your finances, family, or property
  • Last Will and Testament: dictate your legacy and how you’d like your estate divided upon your death
  • Child Medical Consent: give a temporary guardian the authority to make medical decisions on behalf of your child
  • Medical Records Release: request that your medical records be released to you or a third party
  • End-of-Life Plan: outline your wishes for memorial services and what to do with your remains

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