Outline
The Alabama Directive Health Care form is a vital tool for individuals wishing to communicate their medical treatment preferences in the event they become unable to speak for themselves. This form, which includes a Living Will and the option to designate a Health Care Proxy, allows individuals to specify their wishes regarding life-sustaining treatments, such as medications, machines, and procedures that prolong life without curing an illness. It addresses critical scenarios, including being terminally ill or permanently unconscious, providing clarity on whether to receive artificial nutrition and hydration. The document emphasizes the importance of sharing these wishes with family, friends, and healthcare providers to ensure that one's directives are honored. Additionally, individuals can outline any other specific instructions they may have, allowing for a more personalized approach to their healthcare decisions. Finally, the form requires signatures from witnesses and the appointed proxy, ensuring that the directives are legally binding and respected by medical professionals.
Sample - Alabama Directive Health Care Form
ADVANCE DI RECTI VE FOR HEALTH CARE
( Living W ill a nd H ealt h Ca r e 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.
I f I be com e t erm in ally ill or inj ured:
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
Sect ion 1 . Living W ill
I f I Becom e Perm anen t ly 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 tha t 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
Ot he r D ire ctions: 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 hav e 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
Sect ion 2 . I f I need som eone t o speak for m e.
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: _______________________________________________________
Sect ion 3 . The t hings list e d on t his form a re w hat I w ant .
Sect ion 4 . M y signat ure
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: _________________________
Sect ion 5 . W it nesse s ( ne ed t w o w it nesses t o sign)
Sect ion 6 . Signa t ure of Prox y
Form Information
| Fact Name | Details |
|---|---|
| Purpose | This form allows individuals in Alabama to express their medical treatment preferences if they become unable to communicate. |
| Governing Law | The Alabama Advance Directive for Health Care is governed by the Alabama Code, Title 22, Chapter 8, Article 6. |
| Age Requirement | Individuals must be at least 19 years old to complete this form, ensuring they are of sound mind. |
| Life-Sustaining Treatment | Patients can choose whether to receive life-sustaining treatment if terminally ill or injured, with options clearly indicated on the form. |
| Food and Hydration | The form allows individuals to specify their wishes regarding artificially provided food and hydration, if they are unable to eat or drink. |
| Health Care Proxy | Individuals can appoint a health care proxy to make medical decisions on their behalf, though this is not mandatory. |
| Witness Requirement | Two witnesses must sign the form to validate it, confirming the individual’s sound mind and independence from the proxy. |
| Revocation | Individuals can revoke their advance directive at any time by destroying the document and communicating their wishes to someone of age. |
Detailed Guide for Filling Out Alabama Directive Health Care
Filling out the Alabama Directive Health Care form is an important step in expressing your medical treatment preferences. This document allows you to communicate your wishes regarding health care decisions in situations where you may not be able to speak for yourself. Once completed, it is essential to share this form with your family, friends, and healthcare providers to ensure that your choices are respected.
- Section 1: Living Will - Begin by writing your name and confirming that you are at least 19 years old and of sound mind. Indicate your wishes regarding life-sustaining treatment if you become terminally ill or injured by placing your initials next to "yes" or "no."
- Next, indicate your preference regarding artificially provided food and hydration by placing your initials next to "yes" or "no."
- Then, specify your wishes if you become permanently unconscious. Again, place your initials next to your choice regarding life-sustaining treatment.
- Indicate your preference for artificially provided food and hydration in this scenario as well by placing your initials next to "yes" or "no."
- If you have any other specific directions, write them down in the space provided. If you do not have additional directions, place your initials in the designated area.
- Section 2: Health Care Proxy - Decide if you want to name a health care proxy. If you do, provide their name, relationship to you, address, and phone numbers. If you choose not to name one, indicate your preference by placing your initials.
- For the health care proxy, specify whether you want them to make decisions about food and water provided through a tube or IV by placing your initials next to "yes" or "no."
- Next, indicate how you want your health care proxy to follow your wishes by choosing one of the options provided and marking it accordingly.
- Section 3: Understanding Your Wishes - Acknowledge your understanding of the implications of your choices, including any conditions that might affect their implementation.
- Section 4: Your Signature - Fill in your name, birth date, and sign the form to validate your directives.
- Section 5: Witnesses - Two witnesses must sign the form. They should provide their names, signatures, and dates. Ensure that these witnesses meet the requirements outlined in the form.
- Section 6: Signature of Proxy - If you named a health care proxy, they must sign the form to confirm their willingness to serve in this role. If you have a second choice, they should also sign.
After completing the form, review it for accuracy and clarity. Make sure that your wishes are clearly articulated and understood. It is advisable to keep a copy for yourself and provide copies to your health care proxy, family, and healthcare providers.
Obtain Answers on Alabama Directive Health Care
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What is the Alabama Directive Health Care form?
The Alabama Directive Health Care form, commonly referred to as an advance directive, allows individuals to express their wishes regarding medical treatment in the event they become unable to communicate those wishes themselves. This includes preferences about life-sustaining treatment and the designation of a health care proxy to make decisions on their behalf.
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Who can complete this form?
Any individual who is at least 19 years old and of sound mind can complete the Alabama Directive Health Care form. This means that the person understands the information presented and is capable of making informed decisions regarding their health care.
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Is it mandatory to have an advance directive?
No, having an advance directive is not a requirement in Alabama. However, it is highly recommended as it helps ensure that your medical preferences are known and respected in case you cannot communicate them in the future.
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What happens if I do not have a health care proxy?
If you choose not to name a health care proxy, the directions you provide in the form will still be followed. It is important to communicate your wishes to your family and healthcare providers, as they will be responsible for making decisions on your behalf.
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Can I change my mind after completing the form?
Yes, you can change your mind at any time. If you decide to revoke your previous directives, you can do so by tearing up the form and communicating your new wishes to someone who is at least 19 years old, who can then document your updated preferences.
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What does "life-sustaining treatment" mean?
Life-sustaining treatment refers to medical interventions that keep a person alive but do not cure their underlying condition. This can include medications, mechanical ventilation, and other procedures. It is important to specify your preferences regarding such treatments in the directive.
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What if I become pregnant?
If you are pregnant or become pregnant, the choices outlined in the advance directive will not be followed until after the birth of your baby. This provision is in place to ensure the health and safety of both the mother and the unborn child.
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How do I ensure my wishes are respected?
To ensure your wishes are respected, share your advance directive with your healthcare providers, family, and friends. It is also advisable to keep a copy of the directive in a readily accessible location and inform your health care proxy of your preferences.
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What are the requirements for witnesses on the form?
The Alabama Directive Health Care form requires the signatures of two witnesses. These witnesses must be at least 19 years old, not related to you by blood, adoption, or marriage, and not entitled to any part of your estate. They should also not be directly responsible for paying for your medical care.
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Can I include additional instructions in the form?
Yes, you can include additional instructions in the designated section of the form. This allows you to specify any other preferences or directives that are not covered in the standard sections, ensuring your wishes are fully communicated.
Common mistakes
When filling out the Alabama Directive Health Care form, individuals often make several common mistakes that can lead to confusion or misinterpretation of their wishes. One frequent error is failing to provide complete and accurate personal information. This includes not clearly writing their name, date of birth, or contact details. Incomplete information can hinder the ability of healthcare providers to identify the individual and follow their directives.
Another mistake is neglecting to discuss their wishes with the designated health care proxy. Selecting a proxy without having a conversation about preferences and values can create misunderstandings. The proxy may not fully understand what the individual wants, which can lead to decisions that do not align with the individual's wishes.
People also often overlook the importance of initialing the sections regarding life-sustaining treatment and artificially provided food and hydration. Failing to initial these sections can leave the directives ambiguous. As a result, healthcare providers may not know whether to provide these treatments, potentially leading to unwanted outcomes.
Additionally, some individuals forget to include any specific additional directions they may have. Leaving this section blank or not providing clear instructions can lead to confusion about the person's preferences regarding their care. It is essential to communicate all wishes clearly to avoid any misinterpretations.
Another common oversight is not having two witnesses sign the form. The Alabama Directive Health Care form requires two witnesses who meet specific criteria. Skipping this step can render the document invalid, meaning that the individual’s wishes may not be honored when needed.
Lastly, individuals may not update their directives as circumstances change. Life events such as changes in health status, relationships, or personal beliefs can affect one's wishes regarding medical care. Regularly reviewing and updating the directive ensures that it accurately reflects current desires and preferences.
Documents used along the form
The Alabama Directive Health Care form is a crucial document for expressing your medical treatment preferences when you can no longer communicate. Alongside this form, several other documents are often used to ensure your healthcare wishes are respected. Here’s a list of those documents:
- Durable Power of Attorney for Health Care: This document allows you to appoint someone to make medical decisions on your behalf if you become incapacitated. It is broader than a health care proxy, as it can cover a range of decisions beyond just medical treatment.
- Do Not Resuscitate (DNR) Order: A DNR order instructs healthcare providers not to perform CPR if your heart stops or you stop breathing. This document is vital for those who wish to avoid aggressive resuscitation efforts.
- Living Will: Similar to the Alabama Directive Health Care form, a living will specifically outlines your preferences regarding life-sustaining treatments and end-of-life care. It provides clear guidance on your wishes in critical situations.
- Physician Orders for Life-Sustaining Treatment (POLST): This form translates your wishes regarding treatment into medical orders. It is particularly useful for those with serious illnesses, ensuring that your preferences are followed by emergency medical personnel.
- Healthcare Proxy Designation: This document allows you to name a specific individual to make health care decisions for you if you are unable to do so. It is essential for ensuring that your wishes are honored by someone you trust.
- Advance Care Plan: An advance care plan is a comprehensive document that includes your values, preferences, and goals regarding medical care. It serves as a guide for your family and healthcare providers.
- Organ Donation Registration: This document indicates your wishes regarding organ donation after death. It is important for ensuring that your preferences are respected in the event of your passing.
- Emergency Medical Information Form: This form provides crucial information about your medical history, allergies, and current medications. It can help emergency responders provide appropriate care in urgent situations.
- Medical History and Medication List: Keeping an updated list of your medical history and current medications is essential. This document helps healthcare providers understand your health status and make informed decisions.
Having these documents in place can greatly ease the burden on your loved ones during difficult times. They ensure that your healthcare preferences are clear and respected, providing peace of mind for both you and your family.
Similar forms
The Alabama Directive Health Care form is similar to several other documents that serve to communicate an individual's medical wishes. Below are five documents that share similarities with the Alabama Directive Health Care form:
- Living Will: Like the Alabama Directive, a living will allows individuals to specify their preferences regarding medical treatment in situations where they cannot communicate. It typically covers life-sustaining treatments and end-of-life care, ensuring that healthcare providers follow the individual's wishes.
- Durable Power of Attorney for Health Care: This document designates a specific person to make healthcare decisions on behalf of the individual if they become incapacitated. Similar to the health care proxy section of the Alabama Directive, it empowers someone trusted to act in the best interest of the individual.
- Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR if the individual stops breathing or their heart stops. This document aligns with the Alabama Directive's emphasis on respecting a person's wishes regarding life-sustaining treatment.
- Physician Orders for Life-Sustaining Treatment (POLST): A POLST form translates a patient's wishes regarding treatment into actionable medical orders. Similar to the Alabama Directive, it ensures that healthcare providers are aware of and respect the patient's preferences in critical situations.
- Advance Care Planning Documents: These documents include various forms that outline an individual's healthcare preferences and goals for treatment. They serve a similar purpose as the Alabama Directive by facilitating discussions about end-of-life care and ensuring that healthcare providers understand the patient's wishes.
Dos and Don'ts
When filling out the Alabama Directive Health Care form, it’s crucial to follow specific guidelines to ensure your wishes are clearly communicated. Here’s a list of what you should and shouldn’t do:
- Do ensure you are at least 19 years old and of sound mind when completing the form.
- Do discuss your wishes with your family and health care proxy, if you choose to name one.
- Do clearly indicate your preferences regarding life-sustaining treatments and hydration.
- Do sign and date the form in the presence of two witnesses who meet the requirements.
- Don’t leave any sections blank; complete all necessary areas to avoid confusion.
- Don’t assume that your health care proxy will know your wishes without discussing them.
- Don’t forget to inform your doctor and family where the completed form is located.
Misconceptions
Understanding the Alabama Directive Health Care form is essential for making informed decisions about medical care. However, several misconceptions may lead to confusion. Here are six common misconceptions:
- Misconception 1: You must have an advance directive.
- Misconception 2: An advance directive is only for the elderly or terminally ill.
- Misconception 3: If I don't name a health care proxy, my wishes won't be followed.
- Misconception 4: The form is too complicated to complete.
- Misconception 5: I cannot change my mind once the form is signed.
- Misconception 6: Medical professionals can ignore my advance directive.
Many people believe that having an advance directive is mandatory. In reality, it is not required. However, having one can help ensure your medical wishes are known and respected.
This form is relevant for anyone over 19 years old who wants to outline their medical preferences. Unexpected medical situations can arise at any age, making it wise for all adults to consider having an advance directive.
While naming a health care proxy can be beneficial, it is not necessary. The directives outlined in the form will still be honored even if you choose not to appoint someone.
Many individuals find the form straightforward. It guides you through the necessary sections, allowing you to express your wishes clearly and concisely.
You retain the right to change your decisions at any time. Simply tearing up the form and creating a new one is sufficient to update your wishes.
Medical professionals are legally obligated to follow the directives outlined in your advance directive, provided they are aware of it. If a healthcare provider refuses to comply, they must refer you to someone who will.
Key takeaways
Here are some key takeaways about filling out and using the Alabama Directive Health Care form:
- Purpose: This form allows you to express your medical treatment preferences in case you become unable to communicate your wishes.
- Not Mandatory: You are not required to have an advance directive, but having one can provide clarity for your loved ones and medical providers.
- Communication: Ensure your doctor, family, and friends are aware of your advance directive and know its location.
- Life-Sustaining Treatment: Clearly indicate your preferences regarding life-sustaining treatments, including whether you want to receive them if terminally ill or permanently unconscious.
- Health Care Proxy: You can appoint someone to make medical decisions on your behalf if you cannot speak for yourself. This person is known as a health care proxy.
- Witness Requirement: The form requires two witnesses who are not related to you and are at least 19 years old to validate your signature.
- Revocation: You can change or revoke your advance directive at any time by destroying the form and informing someone of your new wishes.