Arkansas Living Will
This Living Will is a legal document that outlines your preferences for medical treatment in the event that you are unable to make decisions for yourself. In accordance with the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, this document serves to communicate your wishes concerning life-sustaining treatment, artificial nutrition, and hydration.
Please provide the following information:
Full Name: ______________________________________________
Date of Birth: ___________________________________________
Address: ________________________________________________
City: ______________________ State: AR Zip Code: ___________
Declaration
I, ______________________________ [your name], a resident of the State of Arkansas, being of sound mind, hereby make this declaration as a directive to be followed should I become permanently unconscious or otherwise unable to communicate my wishes regarding medical treatment.
Directions for Health Care
I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choices I have marked below:
- If I am in a terminal condition, I direct that:
_____ (initial) Treatment be limited to measures intended to keep me comfortable and relieve pain, including any pain that might arise from withholding or withdrawing treatment.
_____ (initial) All available treatments be used to prolong my life, as long as possible, within the limits of generally accepted health care standards.
- If I am in a permanent coma or persistent vegetative state and there is no reasonable expectation of recovery:
_____ (initial) I do not want life-sustaining treatment, except treatment necessary to keep me comfortable and relieve pain.
_____ (initial) I want all treatments necessary to prolong my life as long as possible, within the limits of generally accepted health care standards.
- If I am in a condition where I am unable to communicate and there is no reasonable expectation that my condition will improve, and I am dependent on artificial nutrition and hydration to survive:
_____ (initial) I do not want artificial nutrition or hydration and prefer to let my condition run its natural course.
_____ (initial) I want to receive artificial nutrition and hydration.
Additional Instructions:
(Use this area to add any specific instructions or limitations you wish to place on your health care providers. If you do not have additional instructions, write "None".)
________________________________________________________________________________________________
________________________________________________________________________________________________
Appointment of Health Care Agent
In the event I am unable to make my own health care decisions, I hereby appoint the following person as my health care agent:
Name of Agent: _____________________________________________
Relationship to Me: ________________________________________
Address of Agent: __________________________________________
Phone Number of Agent: _____________________________________
This living will is made voluntarily and without any coercion or undue influence. I understand the consequences of this document, and I am mentally competent to make this living will at the time of its creation.
Signature
_____________________________________ Date: _________________
Signed in the presence of two witnesses, neither of whom is a spouse, heir, attending physician, health care facility administrator where the declarant is receiving care, or any other person who has, at the time of the execution, a claim against any portion of the estate of the declarant.
Witnesses
- Witness 1 Name: _______________________________________
- Address: _______________________________________________
- Signature: ____________________________________________ Date: _________________
- Witness 2 Name: _______________________________________
- Address: _______________________________________________
- Signature: ____________________________________________ Date: _________________