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
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 trea
tments 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
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