"Advance Directive for Health Care" - Arkansas

An Arkansas Advance Directive is a crucial form that allows of-age individuals to have legal control over their medical treatment in the event when they are unable to speak for themselves. When a patient does not have their wishes about the kinds of medical treatment they do or do not want to receive specified, these decisions can be placed in the hands of family members, doctors, or even judges, who may know very little about what the patient prefers. Download a ready-made directive through the link below or make your own form with our customizable template.

The document provides an efficient and flexible format for planning out future health care and gives patients the option of electing a trusted individual or health professional to oversee their care. There is a difference between an Arkansas Advance Directive for Health Care and an Arkansas Living Will. The former are oral or written instructions about future medical care in case the individual becomes too ill to communicate. The latter is a specific type of directive that takes effect only when a patient is terminally ill.

An Arkansas Advance Directive is described in § 20-17-201 (Definitions) to § 20-17-218 (Repeal) of Chapter 17 (Death and Disposition of the Dead) Subchapter 2 (Arkansas Rights of the Terminally Ill or Permanently Unconscious Act).

ADVERTISEMENT

What Is an Arkansas Advance Directive?

An Advance Directive is a document in which an individual states their preferences regarding health care procedures that become effective when they are no longer able to make decisions for themselves. The contents can be updated and changed as often as the individual wishes.

The form includes two parts in total:

  1. A Living Will - a specific type of Advance Directive which can also be used on its own - is a signed and witnessed document called a "declaration" or "directive" with instructions for an attending physician to withhold or withdraw certain medical interventions once the signer is no longer able to verbally make decisions about medical treatment.
  2. A Durable Power of Attorney for Health Care - otherwise known as a Health Care Proxy - is a notarized document in which the signer designates an agent to make healthcare-related decisions on their behalf.

How to Write an Advance Directive in Arkansas?

Advance care directive in Arkansas usually features the following steps:

STEP 1 - Elect a health care proxy - or agent - to make medical decisions on your behalf. Be sure to choose a person willing to respect and follow your wishes

STEP 2 - Write down your wishes regarding any limitations in medical treatment. Specify whether you agree to be on a dialysis machine, extracorporeal membrane oxygenation (ECMO) machine, receive CPR or take antibiotics to treat infections

STEP 3 - Make decisions regarding the possibility of organ and tissue donation and state your preferences regarding burial and the disposition of remains.

STEP 4 - Keep the original signed and certified form, hand a copy out to your agent and ask your doctor to keep a copy of your document with your medical records.

ADVERTISEMENT

Download "Advance Directive for Health Care" - Arkansas

284 times
Rate (4.8 / 5) 20 votes
Arkansas Advance Directive for Health Care
Section I - Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and intentionally, by this Living Will, direct my family,
physician(s), attorney, and any other individuals who may become responsible for my
health and well-being in the future, whether partly or fully, to take the following
actions in each of the circumstances described in the Living Will below.
1. In the event that I develop a condition considered “terminal” with my attending
physician and one other medical professional both agreeing that there is no
chance for improvement, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. In the event that I fall into a coma with my attending physician and one other
medical professional both agreeing that there is no chance for recovery, I direct
the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. In the event that I develop a persistent vegetative state with my attending
physician and one other medical professional both determining that there is no
chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Arkansas Advance Directive for Health Care
Section I - Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and intentionally, by this Living Will, direct my family,
physician(s), attorney, and any other individuals who may become responsible for my
health and well-being in the future, whether partly or fully, to take the following
actions in each of the circumstances described in the Living Will below.
1. In the event that I develop a condition considered “terminal” with my attending
physician and one other medical professional both agreeing that there is no
chance for improvement, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. In the event that I fall into a coma with my attending physician and one other
medical professional both agreeing that there is no chance for recovery, I direct
the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. In the event that I develop a persistent vegetative state with my attending
physician and one other medical professional both determining that there is no
chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4. In addition to the directions I have listed above, I also request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Section II - Health Care Proxy
I would like to appoint __________________________________ with a mailing
address of ____________________________________________________________,
to act as my Health Care Proxy. I have talked with this person about my wishes.
They can be reached at ______________________________ during daytime hours or
at ______________________________​
a t night.
If this person is not able or not willing to serve as my Health Care Proxy, I would like
to appoint __________________________________ with a mailing address of
____________________________________________________________, to act as
my Health Care Proxy. I have talked with this person about my wishes.
They can be reached at ______________________________ during daytime hours or
at ______________________________​
a t night.
I want my Health Care Proxy:
❏ to follow only the directions as listed on this form.
❏ to follow my directions as listed on this form and to make any decisions about
things I have not covered in the form.
❏ to make the final decision, even though it could mean doing something
different from what I have listed on this form.
Section III - Acknowledgement
I understand the following:
If my doctor or hospital refuse to follow the directions I have listed, they must
see that I get to a doctor or hospital who will follow my wishes.
If I am pregnant, or if I become pregnant, the choices I have made on this form
will not be followed until after the birth of the child.
● If the time comes for me to stop receiving life-sustaining treatment or food and
water through a tube or an IV, I direct that my doctor talks about the good and
bad points of doing this, along with my wishes, with my health care proxy, if I
have one.
Section IV - Signatures
Principal
By signing this Advance Directive in front of the witnesses identified below, I hereby
administer and subscribe to the declarations made above both freely and voluntarily,
and wholeheartedly request that my family, physician(s), attorney, and any other
individuals who may in the future become responsible for my health and well-being,
whether partly or fully, all abide by my wishes as stated herein.
_________________________________
Name
_________________________________
Signature
_________________________________
Date of signing
Witnesses
This Advance Directive was signed by _________________________________ in the
presence of the following two witnesses, who by their signatures below, confirm that
_________________________________ was, at the time this document was signed,
at least eighteen years of age, of sound mind, memory, disposition, understanding, not
under any improper influence and able to understand the weight of this decision. The
undersigned have subscribed this document in the presence of each other and
_________________________________ and at their request.
First Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Second Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Health Care Proxy
I, _________________________________, am willing to serve as the health care
proxy.
_________________________________
Signature
_________________________________
Date of signing
I, _________________________________, am willing to serve as the health care
proxy if the other health care proxy will be unable to serve.
_________________________________
Signature
_________________________________
Date of signing
Notary Acknowledgement
STATE OF ARKANSAS
COUNTY OF _________________________________
I, _________________________________, a Notary Public of said County, do certify
that _________________________________, as Principal, and __________________
________________ and _________________________________, as witnesses,
whose names are signed to the writing above bearing date on the _______ day of
______________, ______, have this day acknowledged the same before me.
Given under my hand this _______ day of ______________, ______.
My commission expires: ___________________________________
______________________________________
Signature of Notary Public
Page of 5