Life Sustaining Statute, Alaska

Declaration as Provided by Alaska Statutes, Section 18.12.010: Life Sustaining Declaration

DECLARATION of ______________

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.

Signed this______ day of _____________________, 20____.

Signature:

________________________________________________________________
Place of signing: _____________________
The Declarant is known to me and voluntarily signed or voluntarily directed another to sign this document in my presence.

Witness:
________________________________________________________________
Signature

Address:
________________________________________________________________
Signature

Address:
State of _________________________
__________________________________ Judicial District

The foregoing instrument was acknowledged before me this ______ day of _____________________, 20____ by ___________________.

_________________________________________
Signature of person taking acknowledgment

Declaration as Provided by Alaska Statutes, Section 18.12.010: Life Sustaining Declaration
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Alaska. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

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