Use this form if you want to make your Living Will in the State of Arkansas.
Arkansas Advance Directive for Health Care Form
Text Version of this Form
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Living Will
And
Durable Power of Attorney for Health CareProvided as a public service by
the Health Law Section of the Arkansas Bar AssociationPlease read the Advance Directive Information available on the Arkansas Bar
Association’s website at http://www.arkbar.com/ carefully before completing these forms.NOTE: The form Living Will and Durable Power of Attorney for Health
Care are being provided to you as a public service. The attached forms are
provided “as is” and are not the substitute for the advice of an attorney. By
providing these forms and the Advance Directive Information, neither the
Arkansas Bar Association nor its Health Law Section is providing legal advice
to you. Consult an attorney if you need legal advice of any nature.———————– Page 2———————–
DECLARATION OF LIVING WILL
OF_________________________________
[Name of Declarant]If I should have an incurable or irreversible condition with no hope of recovery that will cause my
death within a relatively short time, and I am no longer able to make decisions regarding my medical
treatment, I direct my attending physician, pursuant to the Common Law and the Arkansas Rights of the
Terminally Ill or Permanently Unconscious Act, to withhold or withdraw treatment that only prolongs the
process of dying and is not necessary to my comfort or to alleviate pain.Additionally, if I should become permanently unconscious, I direct my attending physician,
pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to withhold or
withdraw life-sustaining treatments that are no longer necessary to my comfort or to alleviate pain.Section 1: Life-Sustaining Treatments
The life-sustaining treatments which may be withheld or withdrawn are (check all that apply):
! Cardiopulmonary Resuscitation.
! Mechanical Breathing.
! Major Surgery.
! Kidney Dialysis.
! Chemotherapy.
! Minor Surgery (unless necessary for my comfort or to alleviate pain).
! Invasive Diagnostic Tests.
! Antibiotics.
! Blood Products.
! Other Medications not Necessary for Alleviation of Pain.Add other medical directives, if any________________________________________________
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Section 2: Artificial Nutrition and Hydration
I understand that Arkansas law requires me to make my wishes regarding artificial nutrition and hydration
known separately from the above directions. Therefore, by initialing the appropriate line(s) below, I
specifically:_______ DIRECT that artificial nutrition may be withheld or withdrawn after consultation
with my attending physician._______ DIRECT that artificial hydration may be withheld or withdrawn after consultation
with my attending physician.SIGNED this _____________ day of ______________________________, 20____.
________________________________________
SignatureWe, the undersigned, do hereby certify that the Declarant, ______________________________
subscribed this Declaration of Living Will in our presence, and we, at his or her request, in his or her
presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that
the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue
influence, fraud or restraint and that his or her signature was voluntary.____________________________________ _____________________________________
Witness Witness
____________________________________ _____________________________________
Address Address
____________________________________ _____________________________________
City, State and Zip Code City, State and Zip CodePage 2
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DURABLE POWER OF ATTORNEY FOR HEALTH CARE
OF_________________________________
[Name of Declarant]Pursuant to the Arkansas Durable Power of Attorney for Health Care Act (Ark. Code Ann. § 20-
13-104) (the “Act”), I hereby designate and appoint _____________________________ as my agent, or
attorney in fact, to make decisions regarding my health care during periods when my health care provider
has determined that I lack capacity to decide for myself. Specifically, and not to limit any other rights
prescribed under the Act, my attorney-in-fact shall have the power to have access to my medical records
for treatment or payment decisions; to disclose medical records to others for purposes of treatment,
payment, or health care operations; to employ and discharge physicians; to consent to or refuse to consent
to medical procedures, including the withholding or withdrawal of life-sustaining treatment, and nutrition
and hydration, according to my wishes expressed in my Living Will, or, if my wishes are unclear under
the then existing circumstances of my medical condition, then upon consideration of my best interests as
determined by my physician in consultation with my agent; to admit me to hospitals, including
psychiatric hospitals, nursing homes, or hospice care; and to sign all appropriate forms, consents and
releases in connection with any of said matters.If ___________________________ resigns, or is not able or available to make health care
decisions for me, or if an agent named by me is divorced from me or is my spouse and legally separated
from me, I appoint _____________________________ as successor, with all of the rights and powers
and authority herein stated. The term “health care” shall have the meaning set forth in Ark. Code Ann. §
20-13- 104(c). This Durable Power of Attorney for Health Care shall not be affected by my subsequent
disability or incapacity.SIGNED this _____________ day of ______________________________, 20____.
________________________________________
SignatureWe, the undersigned, do hereby certify that the Declarant, ______________________________
subscribed this Durable Power of Attorney for Health Care in our presence, and we, at his or her request,
in his or her presence, and in the presence of each other, signed as attesting witnesses, and we do further
certify that the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without
undue influence, fraud or restraint and that his or her signature was voluntary.____________________________________ _____________________________________
Witness Witness
____________________________________ _____________________________________
Address Address
____________________________________ _____________________________________
City, State and Zip Code City, State and Zip CodePage 3