Fillable Printable Power of Attorney for Health Care - Arkansas

Power of Attorney for Health Care - Arkansas

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State of Arkansas

Power of Attorney for Health Care

Will to Live Form

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

designate:

(Name of agent)________________________________________________________

(Address of agent)_______________________________________________________

(Phone number(s) of agent)_______________________________________________

as my health care agent to make any health care decisions for me as authorized in this document

consistent with the instructions below.

If the person I designate above refuses or is not able to act for me, I designate the following

persons (each to act alone and successively, in the order named):

A. First Successor Agent

(Successor’s name)______________________________________________________________

(Successor’s address)____________________________________________________________

______________________________________________________________________________

(Successor’s phone number)_______________________________________________________

B. Second Successor Agent

(Second successor’s name)________________________________________________________

(Second successor’s address)______________________________________________________

______________________________________________________________________________

(Second successor agent’s phone number)____________________________________________

as my health care agent(s) to make any health care decisions for me as authorized in this

document consistent with the instructions below.

This designation shall become effective only when I become incapable of making and

communicating my own health care decisions.

Any prior designation is revoked.

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GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care agent(s) to make health care decisions

consistent with my general desire for the use of medical treatment that would preserve my life, as

well as for the use of medical treatment that can cure, improve, reduce or prevent deterioration

in, any physical or mental condition.

Food and water are not medical treatment, but basic necessities. I direct my health care

provider(s) and health care agent to provide me with food and fluids, orally, intravenously, by

tube, or by other means to the full extent necessary both to preserve my life and to assure me the

optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in

order to cause my death.

I direct that the following be provided:

∙ the administration of medication;

∙ cardiopulmonary resuscitation (CPR); and

∙ the performance of all other medical procedures, techniques, and technologies,

including surgery,

–all to the full extent necessary to correct, reverse, or alleviate life-threatening or health

impairing conditions or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of

an unborn or newborn child, who has been subject to an induced abortion. This rejection does

not apply to the use of tissues or organs obtained in the course of the removal of an ectopic

pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner

that causes, contributes to, or hastens that person’s death.

I request and direct that medical treatment and care be provided to me to preserve my life

without discrimination based on my age or physical or mental disability or the “quality” of my

life. I reject any action or omission that is intended to cause or hasten my death.

I direct my health care provider(s) and health care agent to follow the policy above, even if I am

judged to be incompetent.

During the time I am incompetent, my agent, as named above, is authorized to make medical

decisions on my behalf, consistent with the above policy, after consultation with my health care

provider(s), utilizing the most current diagnoses and/or prognosis of my medical condition, in the

following situations with the written special instructions.

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WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only a week or less even

if lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

_____________________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even

though death is not imminent I am in the final stage of that terminal condition – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only three months or less,

even if lifesaving treatment or care is provided to me – the following may be withheld or

withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

C. OTHER SPECIAL CONDITIONS:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

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IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and

health care agent(s) to use all lifesaving procedures for myself with none of the above special

conditions applying if there is a chance that prolonging my life might allow my child to be born

alive. I also direct that lifesaving procedures be used even if I am legally determined to be brain

dead if there is a chance that doing so might allow my child to be born alive. Except as I specify

by writing my signature in the box below, no one is authorized to consent to any procedure for

me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

Signed this _________ day of _________________, 20______.

Signature______________________________________________________________________

Address_______________________________________________________________________

The declarant voluntarily signed this writing in my presence.

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

Form Prepared 2005

Updated 2008

Reviewed 2013