» » Arkansas Living Will Form

Arkansas Living Will Form

Create a high quality document online now!

The Arkansas living will, also referred to as an ‘Advance Care Plan‘, is a declaration made by a person to select their treatment options at the end of their life. This form would only come into use if the person was in a permanent state of incapacitation with no probable chance of a cure. This allows for a death that is comfortable and allows the person to choose to end their life sooner and unassisted by ventilators or feeding machines.

Laws§ 20-17-202

Signing Requirements (§ 20-17-202) – Two (2) Witnesses or a Notary Public.

How to Write

Download: Adobe PDF

Step 1 – Download The Arkansas Living Will Template

The document available through the text-link “Adobe PDF” just above this statement, as well as the “Adobe PDF” button, will give you direct access to the Arkansas Living Will Form. Save this file to your system then access it when you are ready to issue this directive.

Step 2 – Introduce The Arkansas Principal Issuing Medical Powers

Review the declaration statement introducing this Arkansas appointment of power. Notice it contains a space that must be populated with an entry for this statement to apply. Name the Arkansas Principal intent on designating a Health Care Proxy or Agent to make medical decisions in the state of Arkansas on behalf of the issuing Principal. This authority will be limited to the statutes in Ark. Code § 20-17-202 and enables the Arkansas Principal to have a personally elected Representative to make medical decisions when he or she is unable to because of a medical event or condition that prevents effective communication. 

 

Step 3 – Appoint The Arkansas Health Care Proxy With Principal Power

The directive’s next area is labeled with the word “Agent.” Here, the Health Care Proxy or Agent who will be authorized to make the Principal’s medical decisions when needed must be identified. Therefore, identify the Health Care Proxy or Agent on the first available line (labeled “Name”) then continue to the right with an entry of the Health Care Proxy or Agent’s telephone number on the line labeled “Phone #,” and one defining the relationship the Arkansas Health Care Proxy holds with the Principal on the line labeled “Relation.”

 

Step 4 – Dispense The Arkansas Health Care Proxy Contact Address

Next, a production of the physical Arkansas residential address where the appointed Health Care Proxy or Agent can be found is required on the line labeled “Address” in the “Agent” section. 

 

Step 5 – Reserve An Alternate Arkansas Health Care Proxy

There may be some decisions or scenarios where the elected Health Care Proxy or Agent will be ineffectual. That is, unable to act. Additionally, he or she may not be available during a sudden medical event requiring a Health Care Proxy decision. In either case (and many more), making sure that the Principal’s representation is continuous regardless of the elected Health Care Proxy’s status may be a priority. The “Alternate Agent” section of this document allows a Party to be held in reserve should the elected Health Care Proxy be ineffectual, unavailable, or no longer qualified (i.e. revoked) to represent the Principal. Should a scenario occur where the Health Care Proxy’s status or effectiveness changes, the Person identified on the “Name” line in the “Alternate Agent” section can assume the role of the Arkansas Principal’s Health Care Proxy or Agent through this issuance. As with the Agent in the previous section, be prepared to satisfy the lines labeled “Phone #” and “Relation” with a reliable telephone number where the Alternate Agent can be reached and the relationship, he or she holds with the issuing Principal. 

 

Step 6 – Attach The Appropriate Contact Address For The Alternate Proxy

The home address where the Alternate Health Care Agent can be visited physically should be presented on the “Address” line in the “Alternate Agent” section. 

 

Step 7 – Set The Bar For The Principal’s Preferred Quality Of Life

The section titled “Quality Of Life” makes use of several checkbox statements that allow easy documentation of medical conditions that the Arkansas Principal considers a severe detriment to his or her “Quality Of Life.” So much so, that he or she would consider living with such a medical condition would be unacceptable. Carefully review the introduction and choices presented in this area.

 

Step 8 – Indicate The Arkansas Principal’s Willingness To Receive Treatment In A Coma

The first checkbox statement available for review in the “Quality Of Life” section is titled “Permanent Unconscious Condition.” Mark the checkbox corresponding to this statement if the Principal considers being in a coma or being unconscious permanently to be an unacceptable way to live. If you do not mark this checkbox then, it will be assumed that the Arkansas Principal wishes to receive continuous treatment while in a coma with no hope of recovery.  

 

Step 9 – Discuss When The Principal’s Mental Acuity Is Acceptable And Unacceptable

The second statement item in the “Quality Of Life” section wishes a report on the Principal’s acceptance of being in a state of “Permanent Confusion.” This means the Arkansas Principal will be “Unable To Remember, Understand, Or Make Decision” as well as being unable to converse with loved ones or remember them accurately. Mark the checkbox preceding the “Permanent Confusion” statement if the Principal finds this “Quality Of Life” unacceptable. Leave it unmarked if the Arkansas Principal is comfortable with receiving treatment as mandated by state regulations and the attending Arkansas Medical Staff. 

 

Step 10 – Present The Arkansas Principal’s Need To Be Independent

The statement titled “Dependent In All Activities Of Daily Living” defines a situation where the Arkansas Principal can no longer communicate independently, has had his or her mobility significantly reduced, and can no longer maintain the day-to-day activities required for proper hygiene, health care, nutrition, or appearance. If the Principal believes this “Quality Of Life” cannot be tolerated as it is not acceptable then the checkbox associated with this statement should be filled in. If the Principal will accept the standard treatment afforded to Clients in such a scenario, then leave the checkbox unmarked.  

 

Step 11 – Report On The Arkansas Principal’s Status Of Treatment During End-Of-Life Events

The “End-Stage Illness” statement addresses the possibility of the Principal finding himself or herself in the last stages of fatal or severely debilitating illness and unresponsive to any treatment. If the Principal wishes the attending Arkansas Medical Staff to know that he or she does not accept such a “Quality Of Life” then the checkbox corresponding to this statement item should be marked. If this “Quality Of Life” can be accepted by the Arkansas Principal, then leave the corresponding checkbox clear.  

Step 13 – Display The Arkansas Principal’s Resuscitation Order

The first row of the “Treatment” table holds the label “CPR (Cardiopulmonary Resuscitation)” and is preceded by a yes/no checkbox area. Mark the “Yes” box if the Principal is suffering from an unacceptable “Quality Of Life” scenario and is struck down by a condition requiring cardiopulmonary resuscitation (i.e. chest compressions, electric shock).  If the Arkansas Principal does not approve the application of C.P.R. when he or she is living an unacceptable “Quality Of Life” then, select the box labeled “No.” This means Medical Staff reading this will not revive the Principal should his or her heart stop beating. 

 

Step 14 – Report On The Principal’s Willingness To Receive Life Support

The Arkansas Principal can choose to have his or her life maintained with medical attention when he or she has indicated that “Quality Of Life” is unacceptable (using the previous section) by marking the “Yes” box of the second table row in treatment. Examples of requiring medical attention to live include requiring a breathing apparatus to deliver oxygen to the bloodstream or a medication plan to maintain consciousness. The “No” box of the second table row should be selected if the Principal does not wish Arkansas Medical Staff to prolong his or her life with “Life Support/Other Artificial Support” 

 

Step 15 – Furnish The Arkansas Principal’s Plan Should New Medical Conditions Arise

Often, a Principal will suffer or contract another medical condition that requires treatment while suffering from one that subjects him or her to a poor “Quality Of Life.” If he or she wishes to receive whatever medical intervention is necessary to treat the additional or new disease or medical condition, then the “Yes” box attached to the “Treatment Of New Conditions” box. If the Principal does not wish Arkansas Medical Staff to treat any additional or new conditions when he or she suffers from a poor or detrimental “Quality Of Life” defined as unacceptable in the previous section, then the “No” box presented for the third checkbox statement. 

 

Step 16 – Inform The Reviewer If The Arkansas Principal Will Accept Nutrition Or Fluids

The final row of the “Treatment” table addresses the Arkansas Medical Staff’s efforts in administering “Tube Feeding/IV Fluids” to either the Principal’s stomach or bloodstream while the Principal has indicated that he or she suffers from a poor to intolerable “Quality Of Life” (as defined above). If the Principal wishes to approve the Arkansas Medical Staff’s delivery of nutrients/nourishment and fluids/water through the use of tubes during such a scenario then mark the “Yes” box. If the Principal does not wish to accept “Tube Feeding/IV Fluids” when subjected to an unacceptable “Quality Of Life” then select the “No” box next to the label “Tube Feeding/IV Fluids.”

 

Step 17 – Include Any Direct Instructions From The Arkansas Principal

The area attached to the label “Other Instructions, Such As Burial Arrangements, Hospice Care, Etc.” is available to receive direct input from the Arkansas Principal issuing this form. Here, he or she can inform the Arkansas Medical Staff administering treatment what preferences should be put in place, what treatment plans are in direct conflict with his or her wishes, and even any end-of-life or post-life instructions. This area is optional, but the Arkansas Principal is encouraged to utilize it. If more room is required to fully address the Principal’s directives, limitations, restrictions, and concerns then an attachment with this content may be composed and attached. Any attachment to this form should be named on the lines in this section as being a part of this directive.

 

Step 18 – The Arkansas Principal May Enact The Option To Make An Anatomical Gift After Death

The Arkansas Principal has the ability to decide whether or not to make an anatomical gift after death has occurred using this document. The area titled “Organ Donation (Optional)” provides a few checkbox options. If the Principal wishes to donate “Any Organ Tissue” that is needed or his or her “Entire Body” then the appropriate checkbox should be marked. The choices “Any Organ Tissue,” “My Entire Body” and “Only the Following Tissues” have been provided so that the Arkansas Principal can clearly convey his or her wishes. For instance, in the example below the Arkansas Principal has indicated that he or she will donate “Any Organ/Tissue” and nothing else.

 

Step 20 – Execute This Directive With The Arkansas Principal Act Of Signing

The “Signature” section at the end of the directive will provide the wording necessary to inform the Arkansas Principal of the execution requirements for this document. The Arkansas Principal must sign the “Patient” line attached to the “Signature” label after it has been determined that it is a true representation of his or her wishes. Immediately upon signing this line, the Principal must submit the exact calendar date of that day on the line labeled “Date.” 

 

Step 21 – Release This Document For Proper Authentication To Its Execution

The Arkansas Principal has two options of verification available. He or she may have the act of signing witnessed by two individuals who can attest to being competent adults, neither of which are named as the Health Care Agent of the Principal or related to the Principal “…By Blood, Marriage, Or Adoption,” nor hold any eligibility to receive any part of the Principal’s estate after death. Witness Number 1 must read the statements provided beneath the Principal signature then sign the “Signature Of Witness Number 1” line to validate that each is true. Witness Number 2 must also read the two declarations provided then sign the blank line labeled “Signature Of Witness Number 2” line. If the Arkansas Principal has elected to have his or her act of signing notarized, then the execution process of this document must follow the Notary Public’s requirements. Once the Principal’s signature has been supplied and notarized. Review the returned notarized directive making sure that the section beginning with the words “State Of Arkansas” (below the Principal’s signature) has been supplied with the county of signing and the Notary Public’s credentials.   

Related Forms


Advance Directive

Download: Adobe PDF

 

 

 


Durable Power of Attorney

Download: Adobe PDF, MS Word, OpenDocument

 

 

 


Medical Power of Attorney

Download: Adobe PDF

 

 

 



ABOUT SSL CERTIFICATES