advdirective

ADVANCE DIRECTIVE FOR HEALTH CARE

(Living Will and Health Care Proxy)

This form may be used in the State of Alabama to make your wishes known about what medical

treatment or other care you would or would not want if you become too sick to speak for yourself.

You are not required to have an advance directive. If you do have an advance directive, be sure that

your doctor, family, and friends know you have one and know where it is located.

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 am writing down. I know that at any time I can change my mind about these

directions by tearing up this form and writing a new one. I can also do away with these directions by

tearing them up and by telling someone at least 19 years of age of my wishes and asking him or her to

write them down.

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

If I become terminally ill or injured:

Terminally ill or injured is when my doctor and another doctor decide that I have a condition that

cannot be cured and that I will likely die in the near future from this condition.

Life sustaining treatment – 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.

Place your initials by either “yes” or “no”:

I want to have life sustaining treatment if I am terminally ill or injured. ____ Yes ____ No

Artificially provided food and hydration (Food and water through a tube or an IV) – I understand

that if I am terminally ill or injured I may need to be given 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.

Place your initials by either “yes” or “no”:

I want to have food and water provided through a tube or an IV if I am terminally ill or injured.

____ Yes ____ No

Section 1. Living Will

If I Become Permanently Unconscious:

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. I understand that at least one of these doctors must be

qualified to make such a diagnosis.

Life sustaining treatment – Life sustaining treatment includes drugs, machines, or other 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.

Place your initials by either “yes” or “no”:

I want to have life-sustaining treatment if I am permanently unconscious. ____ Yes ____ No

Artificially provided food and hydration (Food and water through a tube or an IV) – I understand

that if I become permanently unconscious, I may need to be given 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.

Place your initials by either “yes” or “no”:

I want to have food and water provided through a tube or an IV if I am permanently unconscious.

____ Yes ____ No

Other Directions: Please list any other things you want done or not done.

In addition to the directions I have listed on this form, I also want the following:

__________________________________________________________________________________

If you do not have other directions, place your initials here:

____ No, I do not have any other directions.

This form can be used in the State of Alabama to name a person you would like to make medical or

other decisions for you if you become too sick to speak for yourself. This person is called a health care

proxy. You do not have to name a health care proxy. The directions in this form will be followed

even if you do not name a health care proxy.

Place your initials by only one answer:

_____ I do not want to name a health care proxy. (If you check this answer, go to Section 3)

_____ I do want the person listed below to be my health care proxy. I have talked with this person

about my wishes.

First choice for proxy: ________________________________________

Relationship to me: __________________________________________

Address: ____________________________________________________

City: ____________________________ State _______ Zip ___________

Day-time phone number: _______________________________________

Night-time phone number: ______________________________________

If this person is not able, not willing, or not available to be my health care proxy, this is my next

choice:

Second choice for proxy: _______________________________________

Relationship to me: __________________________________________

Address: ____________________________________________________

City: ____________________________ State _______ Zip ___________

Day-time phone number: _______________________________________

Night-time phone number: ______________________________________

Instructions for Proxy

Place your initials by either “yes” or “no”:

I want my health care proxy to make decisions about whether to give me food and water through a tube

or an IV. ____ Yes ____ No

Section 2. If I need someone to speak for me.

Place your initials by only one of the following:

____ I want my health care proxy to follow only the directions as listed on this form.

_____ I want my health care proxy to follow my directions as listed on this form and to make any

decisions about things I have not covered in the form.

_____ I want my health care proxy to make the final decision, even though it could mean doing

something different from what I have listed on this form.

I understand the following:

§ 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 directions.

§ If I am pregnant, or if I become pregnant, the choices I have made on this form will not be

followed until after the birth of the baby.

§ If the time comes for me to stop receiving life sustaining treatment or food and water through a

tube or an IV, I direct that my doctor talk about the good and bad points of doing this, along with

my wishes, with my health care proxy, if I have one, and with the following people:

____________________________________________________________________

Your name: _______________________________________________________

The month, day, and year of your birth: _________________________________

Your signature: ____________________________________________________

Date signed: _______________________________________________________

Section 3. The things listed on this form are what I want.

Section 4. My signature

I am witnessing this form because I believe this person to be of sound mind. I did not sign the

person’s signature, and I am not the health care proxy. I am not related to the person by blood,

adoption, or marriage and not entitled to any part of his or her estate. I am at least 19 years of age and

am not directly responsible for paying for his or her medical care.

Name of first witness: ___________________________________

Signature: _____________________________________________

Date: _________________________________________________

Name of second witness: _________________________________

Signature: _____________________________________________

Date: _________________________________________________

I, ____________________________________________, am willing to serve as the health care proxy.

Signature: ________________________________________ Date: _________________________

Signature of Second Choice for Proxy:

I, __________________________, am willing to serve as the health care proxy if the first choice

cannot serve.

Signature: ________________________________________ Date: _________________________

Section 5. Witnesses (need two witnesses to sign)

Section 6. Signature of Proxy