Note:  The purchased version of this form includes, in addition to the Living Will, the Arkansas Durable Power of Attorney for Health Care.

ARKANSAS LIVING WILL DECLARATION

 

            This Declaration is made pursuant to the provisions of the ARKANSAS RIGHTS OF THE TERMINALLY ILL OR PERMANENTLY UNCONSCIOUS ACT as follows:

           

            If the time comes when I can no longer take part in making decisions for my own future, let this statement stand as an expression of my wishes and my declaration while I am of sound mind.

 

            I, ___________________________________________ (the "Declarant"), being of sound mind, having reached the age of eighteen (18) years, residing in the State of Arkansas, do hereby make, publish and declare the following:

 

1.   If I should have an incurable or irreversible condition 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 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.

 

            2.   If I should become permanently unconscious, I direct my attending physician, pursuant to the same Act, to withhold or withdraw life-sustaining treatments which are no longer necessary to my comfort or to alleviate pain.

 

            These life-sustaining treatments which may be withheld or withdrawn include, but are not limited to:

 

                        Antibiotics

                        Artificially Administered Feeding & Fluids

                        Cardiac Resuscitation

                        Respiratory Support

                        Surgery

 

            3.   In the absence of my ability to give directions regarding the use of such procedures, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequence from such refusal.  Therefore, if I should become permanently unconscious, I direct my attending physician to follow the instructions of ___________________________________________, whom I appoint as my HEALTH CARE PROXY to decide whether life-sustaining treatments should be withheld or withdrawn.

 

            4.   It is my intention for my physician or health care provider to be furnished a copy of this declaration and for it to become a part of my medical records and, if they are unwilling to comply with this declaration, to promptly so advise me and my Health Care Proxy.

 

            5.   It is my intention to relieve all persons from any and all civil and criminal liability for good faith reliance on this Declaration in carrying out these instructions, and this Declaration should be construed by my family and attending physicians in the spirit that I do not desire aggressive medical treatment or life-sustaining procedures in any of the circumstances described herein.

 

            6.   I understand the full import of this directive, and I am emotionally and mentally competent to make this Declaration.

 

            7.   Additional Instructions: ______________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
 

            8.   I have discussed my desires concerning terminal care with __________________________________________ and __________________________________________, in addition to my health care proxy and trust them to make decisions for such care in my behalf in the event my health care proxy is unable to do so.

 

            IN WITNESS WHEREOF, I have hereunto set my hand and seal this ______ day of ________________________, 20______.

 

 

__________________________________________

Signature of Person Making Declaration (Declarant)

 

__________________________________________

(Type or Print Name of Declarant)

 

__________________________________________

Street Address

 

__________________________________________

City                              State                   Zip Code

 

NOTICE REGARDING WITNESSES

 

You must have two adult witnesses who will not receive your assets when you die (whether you die with or without a will), and who are not your spouse, child, grandchild, brother or sister, or an employee at the health care facility where you are a patient. 

 

ATTESTATION

 

            Subscribed by ___________________________________________, in the presence of each of us, the undersigned, and at the same time declared by him to us to be his Living Will, and we, thereupon, at the request of the Declarant in his presence and in the presence of each other, sign our names hereto as witnesses this ______ day of ________________________, 20______.

 

 

__________________________________________           __________________________________________

Signature of 1st Witness                                                Signature of 1st Witness

 

__________________________________________           __________________________________________

(Type or Print Name of Witness)                                      (Type or Print Name of Witness)

 

__________________________________________           __________________________________________

Street Address                                                              Street Address

 

__________________________________________           __________________________________________

City                              State                   Zip Code        City                              State                   Zip Code

 

 

            Subscribed and acknowledged before me by the said __________________, Declarant, and subscribed and sworn to before me by the said ___________________________________________, ___________________________________________, witnesses, on this ______ day of ________________________, 20______.

 

 

__________________________________________

Notary Public

 

My Commission Expires: ______________________

Other Forms You May Need

• Arkansas General Durable Power of Attorney for Property & Finances (Immediate)
• Arkansas General Durable Power of Attorney for Property & Finances (Upon Disability)
• HIPAA Authorization and Waiver