Healthcare Power of Attorney - Alabama

ALABAMA HEALTH CARE PROXY DESIGNATION

AND TREATMENT INSTRUCTIONS

Important Information

This document appoints a health care proxy under the Alabama Natural Death Act
to make decisions concerning life-sustaining treatment and artificially
provided nutrition and hydration when the statutory activation conditions are
met. It is not a financial power of attorney. Any broader health-care authority
should be reviewed separately under current Alabama power-of-attorney law.

The person making this designation must be a competent adult at least 19 years
old. The proxy must accept the appointment in writing, and the acceptance must
be attached to the designation.

1. Principal

Name: [FULL LEGAL NAME]

Date of birth: [__/__/____]

Address: [ADDRESS]

Telephone: [TELEPHONE]

2. Primary Health Care Proxy

I appoint:

Name: [PRIMARY PROXY NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Daytime telephone: [TELEPHONE]

Other telephone: [TELEPHONE]

3. Successor Health Care Proxy

If my primary proxy is unable, unwilling, or unavailable to serve, I appoint:

Name: [SUCCESSOR PROXY NAME]

Relationship: [RELATIONSHIP]

Address: [ADDRESS]

Daytime telephone: [TELEPHONE]

Other telephone: [TELEPHONE]

My health-care provider may not act as my proxy. An employee of my provider may
not act as proxy unless that employee is my relative.

4. Proxy Authority and Decision Standard

When this designation is effective, my proxy may decide whether to provide,
withhold, or withdraw life-sustaining treatment in cases of terminal illness
or injury or permanent unconsciousness.

Initial one choice concerning artificially provided nutrition and hydration:

[____] Yes, my proxy may decide whether to provide, withhold, or withdraw
food and water through a tube or intravenous line.

[____] No, my proxy may not withhold or withdraw food and water through a
tube or intravenous line.

My proxy must follow my specific instructions and other known wishes. Without
specific guidance, my proxy must decide as closely as possible to what I would
have intended, considering my personal, philosophical, religious, moral, and
ethical beliefs and how I would have weighed treatment burdens and benefits.

5. Relationship Between Proxy and Written Instructions

Initial only one:

[____] My proxy must follow only the instructions in this document.

[____] My proxy must follow my instructions and may decide matters I have
not addressed.

[____] My proxy may make the final decision even if it differs from an
instruction in this document.

Unless I provide otherwise, my proxy’s decision concerning life-sustaining
treatment or artificially provided nutrition and hydration takes precedence
over a living-will instruction.

Different instruction or limitation: [DESCRIBE OR “NONE”]

6. Treatment Instructions

Terminal Illness or Injury

Initial one choice for life-sustaining treatment:

[____] Yes, provide life-sustaining treatment.

[____] No, withhold or withdraw life-sustaining treatment while continuing
medication and care needed to ease pain and keep me comfortable.

Initial one choice for artificially provided nutrition and hydration:

[____] Yes, provide food and water through a tube or intravenous line.

[____] No, withhold or withdraw food and water through a tube or intravenous
line.

Permanent Unconsciousness

Initial one choice for life-sustaining treatment:

[____] Yes, provide life-sustaining treatment.

[____] No, withhold or withdraw life-sustaining treatment while continuing
medication and care needed to ease pain and keep me comfortable.

Initial one choice for artificially provided nutrition and hydration:

[____] Yes, provide food and water through a tube or intravenous line.

[____] No, withhold or withdraw food and water through a tube or intravenous
line.

Additional directions: [DESCRIBE]

7. When Proxy Authority Becomes Effective

This designation becomes effective only when both of the following occur:

• My attending physician determines that I can no longer understand,
  appreciate, and direct my medical treatment; and

• Two physicians, including my attending physician and a physician qualified
  and experienced in making the diagnosis, personally examine me and document
  in my medical record that I am terminally ill or injured or permanently
  unconscious.

My own wishes supersede this designation whenever I am competent to decide.

If my attending physician knows that I am pregnant, this designation has no
effect during the pregnancy.

8. Revocation and Former-Spouse Designation

I may revoke this designation or another part of this advance directive by:

• Destroying or defacing the directive in a manner indicating an intent to
  cancel;

• A signed and dated written revocation by me or by a person acting at my
  direction; or

• A verbal expression of intent to revoke in the presence of one witness who
  is at least 19 years old and signs and dates a confirming writing.

A verbal revocation becomes effective when my attending physician or provider
receives the witness’s confirming writing and records receipt in my medical
record.

Unless this designation or a qualifying decree or legal-separation order
provides otherwise, divorce, dissolution, or annulment of marriage revokes a
former spouse’s proxy designation.

9. Principal’s Signature

Signature: ____________________________________

Printed name: [FULL LEGAL NAME]

Date signed: [__/__/____]

10. Two Witnesses

Each witness must be at least 19 years old. Neither witness may be the person
who signed for the principal, a named proxy, related to the principal by blood,
adoption, or marriage, entitled to part of the principal’s estate by intestate
succession or under a will or codicil, or directly financially responsible for
the principal’s medical care.

We believe the principal is of sound mind. The principal signed this document,
or directed another person to sign it, in our presence.

Witness 1

Signature: ____________________________________

Printed name: [WITNESS 1 NAME]

Address: [ADDRESS]

Date: [__/__/____]

Witness 2

Signature: ____________________________________

Printed name: [WITNESS 2 NAME]

Address: [ADDRESS]

Date: [__/__/____]

11. Written Proxy Acceptances

Primary Proxy

I, [PRIMARY PROXY NAME], accept appointment and am willing to serve as
health care proxy.

Signature: ____________________________________

Date: [__/__/____]

Successor Proxy

I, [SUCCESSOR PROXY NAME], accept appointment and am willing to serve if
the first choice cannot serve.

Signature: ____________________________________

Date: [__/__/____]

Sources and References

• Ala. Code § 22-8A-4 — Health care proxy designation and statutory form
• Ala. Code § 22-8A-5 — Revocation
• Ala. Code § 22-8A-6 — Proxy decision standard
• Ala. Code §§ 22-8A-7 through 22-8A-9 — Competency, immunity, refusal, and court jurisdiction