ARKANSAS ADVANCE DIRECTIVE

I, [NAME], hereby give these advance instructions on how I want to be treated by my doctors and other health care providers when I can no longer make those treatment decisions myself.

Agent: I want the following person to make health care decisions for me:
Name: [NAME]
Phone #: [PHONE NUMBER]
Relation: [RELATION]
Address: [ADDRESS, CITY, STATE, ZIP CODE]

Quality of Life:
I want my doctors to help me maintain an acceptable quality of life including adequate pain management. A quality of life that is unacceptable to me means when I have any of the following conditions:

◻ Permanent Unconscious Condition: I become totally unaware of people or surroundings with little chance of ever waking up from the coma.
◻ Permanent Confusion: I become unable to remember, understand or make decisions. I do not recognize loved ones or cannot have a clear conversation with them.
◻ Dependent in all Activities of Daily Living: I am no longer able to talk clearly or move by myself. I depend on others for feeding, bathing, dressing and walking. Rehabilitation or any other restorative treatment will not help.
◻ End-Stage Illnesses: I have an illness that has reached its final stages in spite of full treatment. Examples: Widespread cancer that does not respond anymore to treatment; chronic and/or damaged heart and lungs, where oxygen needed most of the time and activities are limited due to the feeling of suffocation.

Treatment: If my quality of life becomes unacceptable to me and my condition is irreversible (that is, it will not improve), I direct that medically appropriate treatment be provided as follows. Checking “yes” means I WANT the treatment. Checking “no” means I DO NOT want the treatment.

◻ Yes
◻ No

CPR (Cardiopulmonary Resuscitation): To make the heart beat again and restore breathing after it has stopped. Usually this involves electric shock, chest compressions, and breathing assistance.

◻ Yes
◻ No

Life Support / Other Artificial Support: Continuous use of breathing machine, IV fluids, medications, and other equipment that helps the lungs, heart, kidneys and other organs to continue to
work.

◻ Yes
◻ No

Treatment of New Conditions: Use of surgery, blood transfusions, or antibiotics that will deal with a
new condition but will not help the main illness.

◻ Yes
◻ No

Tube feeding/IV fluids: Use of tubes to deliver food and water to patient’s stomach or use of IV fluids into a vein which would include artificially delivered nutrition and hydration.

◻ Yes
◻ No

DURABLE POWER OF ATTORNEY FOR HEALTH CARE OF
[NAME]

Pursuant to the Arkansas Healthcare Decisions Act (Ark. Code Ann. § 20-6-101 et seq.) (the “Act”), I hereby designate and appoint [NAME] as my agent, or attorney-in-fact, whose phone number is [PHONE NUMBER], to make decisions regarding my health care during periods when my health care provider has determined that I lack capacity to decide for myself. Specifically, and not to limit any other rights prescribed under the Act, my attorney-in-fact shall have the following powers:

(a) To consent, refuse, or withdraw consent to any and all types of medical care, treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical or other procedures that affect any bodily function, including, but not limited to, artificial respiration, nutritional support and hydration, and cardiopulmonary resuscitation;
(b) To have access to medical records and information to the same extent that I am entitled to, including the right to disclose the contents to others;
(c) To authorize my admission to or discharge, even against medical advice, from any hospital, nursing home, residential care, assisted living or similar facility or other healthcare facility;
(d) To contract on my behalf for any health care related service or facility on my behalf, without my agent incurring personal financial liability for such contracts;
(e) To select and discharge medical, social service, and other support personnel responsible for my care;
(f) To authorize, or refuse to authorize, any medication or procedure intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten the moment of, but not intentionally cause, my death;
(g) To take any other action necessary to do what I authorize here, including but not limited to granting any waiver or release from liability required by any hospital, physician, or other health care provider; signing any documents relating to refusals of treatment or the leaving of a facility against medical advice; and pursuing any legal action in my name, and at the expense of my estate, to force compliance with my wishes as determined by my agent, or to seek actual or punitive damages for the failure to comply.

This Power of Attorney for Health Care shall give my agent the authority to make decisions about withholding or withdrawal of life-sustaining treatment, and nutrition and hydration, according to my wishes expressed in my Living Will, Health Care Directive, and/or Advance Care Plan, or if my wishes are unclear under the then existing circumstances of my medical condition, then upon consideration of my best interest as determined by my physician in consultation with my attorney-in-fact.

SIGNED this [DAY] day of [MONTH], 20[XX].

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Signature

We the undersigned, do hereby certify that the Declarant, [NAME], subscribed this Durable Power of Attorney for Health Care in our presence, and we, at his/her request, in his/her presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue influence, fraud, or restraint and that his or her signature was voluntary.

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Print Witness Name
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Signature of Witness
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Print Witness Name
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Signature of Witness