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Arkansas Advance Directive Form

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An Arkansas advance directive lets someone choose medical treatment wishes and choose a person to make health care decisions on their behalf. The form is used as a guide for a hospital on how to treat someone in the chance they should become permanently incapacitated with no possible cure. For these reasons, it is common for elderly individuals or people with severe health issues.

Advance Directive Includes

Table of Contents

Laws

Statutes – § 20-6-101 to § 20-6-118 (Arkansas Healthcare Decisions Act)

Signing Requirements (§ 20-6-103(c)) – Two (2) witnesses or a notary public.

Versions (2)


Arkansas Dept. of Health

Download: Adobe PDF

 

 

 


Arkansas Legal Services

Download: Adobe PDF

 

 

 

How to Write

Download: Adobe PDF

Step 1 – Acquire The Arkansas Advanced Directive Template

The Arkansas Advance Directive is a downloadable “PDF” document using the button bearing this label or the text-link reading “Adobe PDF” above.

Step 2 – Declare Yourself As The Principal Behind This Directive

Once you have saved then opened your Arkansas Directive, locate the first blank line it presents. It will be assumed that you are the Principal issuing this document and not a Preparer. The full name of the Party granting the responsibility and authority to make certain medical decisions must be placed on this line. If you are the Principal granting his or her power to an Agent through this form then, enter your full name on this line.  

 

Step 3 – Formally Appoint The Arkansas Medical Attorney-in-Fact Or Health Care Agent

The next task will be to document some information defining the Party you wish to grant authority to. First, locate the section labeled with the bold word “Agent.” The individual that you name in the blank line labeled “Name” in this section will have the authority to make medical decisions for you, view your medical records, and take actions on your behalf when you are unable to communicate or are unconscious. Notice two additional items immediately follow the “Name” of your Health Care Agent. Follow these labels to continue identifying your Health Care Agent by recording his or her telephone number on the line labeled “Phone” and documenting how he or she is related to you (the Principal). Once you have defined your Health Care Agent (or Medical Attorney-in-Fact) with his or her “Name,” “Phone #” and “Relation” to you. Continue to the next line labeled “Address.” Produce the full home address maintained by your Medical Attorney-in-Fact on this line.  

 

Step 4 – Designate An Alternate Agent With The Authority To Assume Principal Power If Needed

This form will also accommodate the naming of an Alternate Health Care Agent. This is a precautionary measure. An Alternate Health Care Agent will not be able to represent you with principal authority unless the Health Care Agent you previously named is unable to represent your interests, refuses to do so, or otherwise has his or her powers revoked. In such a case, you would be left without representation unless you appoint an Alternate Health Care Agent. To set this option in motion, locate the bold label “Alternate Agent,” then review the statement provided. When ready, furnish the full “Name” of your Health Care Agent along with his or her “Phone #” then, define how he or she is related to you on the blank lines labeled “Name,” “Phone #,” and “Relation” (respectively).  Once you have appointed the Alternate Health Care Agent, continue his or her identification process by documenting his or her “Address” on the next available line in the “Alternate Agent” section. 

 

Step 5 – Discuss When Your Quality Of Life Should Be Maintained

The next section is set to discuss your preferences regarding the “Quality Of Life” you wish maintained when you are incapacitated or are unable to communicate. Here some basic documentation regarding when you wish the care you receive and the pain management in place to continue and if or when you wish it withdrawn will be discussed. In the “Quality Of Life” section, several checkbox definitions are on display. You may check as many as you wish to define when you believe your “Quality Of Life” no longer mandates life-prolonging care (including pain management). For example, locate the first checkbox of this list (“Permanent Unconscious Condition”). If you wish medical care withdrawn if you have lost consciousness and have little to no hope of waking up (i.e. a permanent vegetative state or coma), then mark the first checkbox. This action will mean that when you reach a “Permanent Unconscious Condition,” medical care will be withheld. If you wish medical care to continue even when in a “Permanent Unconscious Condition” then, do not mark this checkbox. Select the second checkbox to indicate that you wish all medical care to prolong your life and manage pain to be ceased when you reach a state of “Permanent Confusion.” If you mark the second checkbox of this list, then you will indicate that you do not approve or accept any medical care when you are “Unable To Remember, Understand, Or Make Decisions” and no longer recognize loved ones. If you wish to continue receiving medical care and pain management if this scenario comes to pass, then do not mark the second checkbox (“Permanent Confusion”).  The third option will allow you to decide whether or not receive medical care and be kept as pain-free as possible if you are “Dependent In All Activities Of Daily Living,” meaning that you no longer have the capacity to perform basic day-to-day functions such as speaking clearly, have lost mobility, and can no longer feed or bathe independently, If you approve of medical care treatment and pain management techniques when you reach this state then do not mark the third checkbox. If you do not wish to receive any such medical care when in this state, then mark the checkbox labeled “Dependent In All Activities Of Daily Living.”  Mark the final checkbox, if you do not wish medical care or pain management administered if you are at the “End-Stage” of a fatal illness. That is, if you are suffering an illness that has run its course, no other treatment options, and are in a stage where death is inevitable, then select this box to discontinue medical care or leave it unmarked to continue receiving medical care in this scenario.  

 

Step 6 – Define When Treatment Should Be Administered Or Withheld

The “Treatment” section shall discuss the topic of medical intervention. Several Yes/No statements have been provided in the “Treatment” section which will allow you to either approve a certain type of medical intervention when your quality of life has deteriorated with little no chance of recovery or to refuse that treatment. the first statement “CPR (Cardiopulmonary Resuscitation)” presents a “Yes” box and a “No” box on its left. If you approve of CPR being used to resuscitate you (i.e. manual or electric) then mark the box labeled “Yes.” If you do not wish to receive “CPR…” during a life-threatening medical event after your quality of life has irrevocably deteriorated, then mark the box labeled “No.”  Another type of medical intervention is the life support machine and other such equipment. If your health has compromised your ability to live comfortably and independently but you wish to be maintained by medical equipment, then mark the box labeled “Yes” in the second choice “Life Support/Other Artificial Support.”   If not, and do not approve of “Life Support/Other Artificial Support” employed then mark the checkbox labeled “No” for the second definition.  If you wish to receive “Treatment Of A New Condition” using surgeries, transfusion, and medication even if it does not contribute to the treatment of a life-threatening preexisting condition then mark the “Yes” box for the fourth statement. If not, then mark the “No” checkbox. The next topic will be that of “Tube Feeding” and “IV Fluids.” This is sometimes necessary to make sure that you are properly hydrated and that your nutrition needs are satisfied. If you wish to continue receiving “Tube Feeding/IV Fluids” even when your quality of life has degraded to an unacceptable degree, then mark the box labeled “Yes” in the fourth selection.   If you do not consent to receive your nutrients and fluids through “Tube Feeding/IV Fluids” when your health has deteriorated, then mark the “No” checkbox. 

 

Step 7 – Supplement The Declaration With Specific Information

 While the first page has named your Agents then requested a direct report on your preference in certain medical situations, the second page will discuss how your Medical Attorney-in-Fact or Health Care Agent can represent you. Some preliminary information will need to be set up beforehand. Thus, fill in the blank line displayed on page two’s title “Durable Power Of Attorney For Health Care Of” with your full name. This must be the name of the Principal therefore, if you are only preparing this document for signing, then record the full name of the Principal to this line.    The first paragraph presented contains some necessary language for naming a Medical Attorney-in-Fact to represent a Principal with health care decision-making powers. Locate the first blank line of this paragraph, following the words “…I Hereby Designate And Appoint,’ then produce the full name of the Health Care Agent or the Attorney-in-Fact on this line to complete the current phrase.  In addition to his or her name, the second blank space in this paragraph will require the Agent’s current telephone number documented.  

 

Step 8 – Approve Or Remove The Types Of Principal Authority Being Granted

A brief list will dictate what the Medical Attorney-in-Fact or Health Care Agent can do in your name. You have the option of crossing out any of the items presented, especially if another document is set in place to work with this one. Every item should be reviewed carefully before proceeding to the next one. If any paragraph item defines powers you do not intend to deliver to the Agent, then you may cross it out or cross out the specific power that he or she should not have. If a paragraph item is left intact, then it shall apply to the Medical Attorney-in-Fact’s scope of principal authority when representing you. For instance, item “(A)” will indicate that you give the Health Care Agent the authority “To Consent, Refuse Or Withdraw Consent” on your behalf for “…Any And All Types Of Medical Care…” Read this paragraph item carefully. If you agree the Health Care Agent may represent you in the defined matters, then leave this paragraph intact. If you disagree with any part or with the paragraph item, then draw a line through the language you do not with applied. If your Health Care Agent should have the same authority you carry regarding access to your medical records (including disclosure) then leave item “(B)” unedited. You may place limits on this item by crossing it or any part it contains that should not be within the Agent’s scope of powers.    The Medical Attorney-in-Fact or Health Care Agent will have the authority to authorize your “Admission To Or Discharge” from a medical facility (i.e. hospitals, nursing/residential care, etc.) if you leave item “(C)” unedited and intact. If you do not wish the Agent to have this type of power, then you may cross out this item. If you wish the Agent to have the power but not if it is converse to medical advice, then locate the phrase “…Even Against Medical Advice,” then cross it out.  The fourth paragraph statement of principal authority, item “(D),” grants the Attorney-in-Fact the power to contract medical personnel and facilities that your care requires without incurring a financial obligation to pay for them out-of-pocket. It is strongly recommended that you speak with your Health Care Agent (and seek a consultation with an appropriate professional) if you do not wish to grant this power. To apply this statement, leave it as is. Otherwise, cross out item “(D)” if you do not wish the Health Care Agent to retain this financial protection.  Item “(E)” grants the Medical Attorney-in-Fact or Health Care Agent with the principal power necessary “To Select And Discharge” medical personnel, social services, and other medically relevant care providers in your name. If you do not wish this power to be granted to the Attorney-in-Fact or Health Care Agent, then cross out item “(E).”  The next item, “(F),” defines the Medical Attorney-in-Fact or Health Care Agent’s principal authority regarding your pain management. If you wish the Attorney-in-Fact to make decisions or even take action (i.e. deliver/withdraw your consent) regarding your pain management programs, then leave this item unedited. If the Medical Attorney-in-Fact or Health Care Agent is not authorized to initiate, alter, or end your pain management programs, then cross out item “(F).”  Item “(G)” will give the Health Care Agent as many abilities and decision-making powers that are left deliverable in the state yet left unmentioned thus far. You may cross it out entirely or simply remove the parts that define power being granted to the Health Care Agent. This will include the ability to go against medical advice. Cross out any parts that should not apply or the entire item if desired. If you wish the Health Care Agent to be given this type of power, then leave item “(G)” unaltered. 

 

Step 9 – Tend The Final Paragraph With Required Material

After you have named the Medical Attorney-in-Fact (or Health Care Agent) and confirmed the health care decisions and actions he or she may on your behalf if you are incapacitated, proceed to the last paragraph. This paragraph will allow an Alternate Attorney-in-Fact to be placed on the roster. This entity will not have any principal powers granted initially. Principal authority will only be granted if the Primary Medical Attorney-in-Fact is no longer occupying or fulfilling his or her role. To name this Party, the current paragraph requires some material input. Locate the first blank space it presents then generate the full name of the Primary Medical Attorney-in-Fact. This space may be found preceding the term “Resigns Or Is Not Able, Available, Or Willing….” Use the second blank line to appoint the Alternate Medical Attorney-in-Fact by populating its content with his or her full name.  

 

Step 10 – Nominate A Conservator Or Guardian If Desired

At times, the courts may determine that a Guardian of your person and/or estate must be appointed by the state or by the federal government. The courts making this decision may not necessarily choose the Medical Attorney-in-Fact you have elected above and are not required to do so. You may nominate a Guardian using the lightly colored text just before the signature area. Be advised that even if you nominate a specific Party to this role, the courts may decide otherwise, however oftentimes the nomination of the Principal is weighed heavily. To take advantage of this option, locate the bracketed label “FULL NAME” then replace it with your Nominee’s full name.  Conclude your nomination by recording your Nominee’s “Full Address” and “Phone Number” by replacing the final two bracketed items with this information. Make sure that the address and telephone number here must be up-to-date methods of communication monitored by your Nominee.  

 

Step 11 – Execute The Arkansas Directive In A Proper Manner

Your signature as the Principal is a mandatory item for this paperwork to go in effect thus setting your Medical Attorney-in-Fact in place. To verify the legitimacy of your signature, it must be submitted either in the presence of two Witnesses or a Notary Public. Once you have met the preferred party, locate the capitalized word “Signed” then produce the two-digit calendar day, the full name of the month, and the two-digit year of the current date across the three lines that follow.  Sign your name on the blank line labeled “Signature” immediately after you have finished entering the above date. Once this task is performed release this paperwork to the Party who shall verify your action.  

 

Step 12 – Complete The Witness Declaration Before Its Presentation

If you have arranged to sign the Arkansas Directive in effect before two Witnesses, make sure that the blank line presented in the testimonial is provided with your name. You may locate this paragraph below your signature and the blank space after the phrase “…Hereby Certify That The Declarant” 

 

Step 13 – Each Witness Must Provide A Testimony

Notice that two distinct areas have been supplied. Each Witness must select a unique area then read the full paragraph. If this paragraph is true, then the first Witness must print his or her name on the blank line labeled “Print Witness Name” in section “1.”  After printing his or her name, the Arkansas Directive’s First Signature Witness must sign the “Signature Of Witness” line in the first section below the testimonial. The Arkansas Directive’s Second Signature Witness must also have read the testimonial provided then record his or her full name in print on the blank line labeled “Print Witness Name.”   Once the printed name of the Arkansas Directive’s Second Signature Witness has been produced, he or she must locate the “Signature Of Witness” line in section “2” then tender his or her signature on it. 

 

Step 14 – Review The Notary Public’s Report If Applicable

If you have decided upon having your signature verified through the notarization process, then you must follow the Notary Public’s signature instructions. Once he or she returns this paperwork locate the “Acknowledgment” page. The Notary Public will have documented the signing’s location, your name, the signing’s date, as well as his or her credentials. 

 

Step 15 – An Optional Do Not Resuscitate Order Has Been Included

A second form is available through this package. If you would like to institute a “State Of Arkansas Emergency Medical Services Do Not Resuscitate Orders,” then continue to the next page of this package then fill in the full name of the Patient on the first blank line.  Your signature, as the Patient or as the Patient’s Proxy or Agent, should be produced on the “Signature Of Patient Or Health Care Proxy Or Legal Guardian” line along with the current “Date.” The Do Not Resuscitate Order must be reviewed by the Attending Physician or Primary Physician of the Patient, he or she must the “Signature Of Attending Physician” line to the statement above it is true then produce his or her phone number on the “Physician’s Telephone Number (Emergency #) line.” In addition to his or her signature and phone number, the Physician must also supply his or her name in print and the date of his or her signature on the blank lines “Physician’s Printed/Typed Name” and “Date Order Written” lines, respectively.  

 

Step 15 – Review The Optional POLST Form

An optional form, the POLST form, may only be filled out by a Physician then reviewed by the Patient. This form will establish how the Patient will be treated when admitted to a medical facility (i.e. hospital) and is meant to officially convey through a Physician’s orders what the Patient will and will not tolerate. The first line of the POLST form should be supplied with the Patient’s “Full Name,” “Date Of Birth,” and “Gender.” While quite a bit of the form is optional and must only be filled out by a Physician, the sections identifying the Patient and the Physician are mandatory.  The Physician’s “Printed Name” and “Phone Number” should be supplied to the next area provided.  If the Patient has an “Additional Contact” then supply the Contact Person’s full “Printed Name” and “Phone Number” on the next line before the Physician’s instructional area.

 

Step 16 – Review The Optional Physician Completed POLST As Needed

As mentioned earlier only the Patient’s Physician may fill out the POLST. The Patient must review this completed document keeping in mind that if a preference is not indicated then full treatment will be administered by default. 

 

Step 17 – Execute The POLST Form With The Physician

The “Signature Of Physician” section must also be completed by the Physician who has submitted information to the POLST form. He or she must present his or her full name (printed), telephone number (for Medical Care), and “Physician License #” as identification to the three boxed areas on the first line available in this section.  The Physician must sign the “Physician Signature” line and supply the appropriate POLST Form signature “Date.”  Next, the Patient’s printed name must be presented in the first box under “Signature Of Patient Or Legal Representative.” In some cases, the Patient may not be the Signature Party. If this is the case, then the Signature Party must also identify the “Relationship” he or she has with the Patient in the next box. If the Patient is self-representing then he or she should write in the term “Self” to the Relationship box. Once, the Signature Party is identified, then the “Signature” line must be signed (in this example, the Patient must sign this line since he or she is not using a Representative). Additionally, the “Date” when this signature is supplied must be recorded.  The final requirement of the “Signature Of Patient Or Legal Representative” section is the Patient’s “Mailing Address” and “Phone Number.” These entries must be where the Signature Party may be contacted by mail and by “Phone.”

 

Step 18 – Include Unaddressed Directives As Needed

A final area has been supplied where you may either speak directly (and freely) to the Medical Personnel utilizing this form or with an attachment. Thus, if desired, locate the set of lines labeled with the words “Other Instructions, Such As Burial Arrangements, Hospice Care, Etc” then record any remaining preferences, instructions, limitations, scenarios that you wish to discuss. If more room is needed, then it is recommended you draw up a properly titled attachment, document the title in this area, then make sure it is present at the time of signing. 

 

Step 19  –  An Optional Organ Donation Area May Be Completed

If a discussion regarding organ donations must be pursued then mark the checkbox labeled “Any Organ/Tissue,”  “My Entire Body,” or  “Only The Following Organs/Tissues.” In the example below, the Patient only wishes to donate organs and tissue and nothing more however, if more information should be conveyed here, then the last box should be marked to indicate the Patient will deliver additional instructions using the blank lines provided or an attachment he or she cites in this area.   

 

Step 20 – The Patient Must Execute This Document To Place It In Effect

The Patient should take a moment to carefully review all of the completed. If it is an accurate representation of his or her medical care directives then he or she must sign the line labeled “Patient” immediately after the word “Signature.” Once this action has been completed, the “Date” when this action occurred should be reported on the adjacent line.

 

Step 21 – Supply Authenticity To The Executing Signature

Two sections have been provided at the end of this paperwork where the Patient’s signature may be verified as accurate. The first of these will supply two separate testimonials each needing one Witness Signature. The first Witness must sign his or her name on the “Signature Of Witness 1” line to testify that he or she has observed the Patient’s executing signature as a Witness who cannot act as the Patient’s Agent. The second Witness must sign the “Signature Of Witness 2” line as verification that he or she has observed the Patient signing, that he or she is not an Agent of the Patient, is not entitled to an inheritance (from the Patient),  and that he or she is not related to the Patient in any way. The final section is strictly for the use of the Notary Public observing the signing and submitting the executed document to the notarization process so that it may be shown as an authentic execution in the future.

 

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