Arkansas Living Will
This Living Will is created in accordance with the Arkansas Living Will Act (Arkansas Code § 20-17-201 et seq.). It expresses my wishes regarding medical treatment in the event that I become unable to communicate my preferences.
Personal Information:
- Full Name: ______________________________________
- Date of Birth: __________________________________
- Address: ______________________________________
- City, State, Zip: _____________________________
- Phone Number: ________________________________
Declaration:
I, the undersigned, being of sound mind, do hereby declare this Living Will to be my directive regarding medical treatment in the event that I am unable to make decisions for myself. This directive is made in accordance with Arkansas law.
My Wishes Regarding Medical Treatment:
- If I am diagnosed with a terminal condition, I do not wish to receive life-sustaining treatment that would only prolong the dying process.
- If I am in a persistent vegetative state with no reasonable chance of recovery, I do not wish to receive life-sustaining treatment.
- I wish to receive comfort care and pain relief, even if it may hasten my death.
- I wish to have the following specific treatments withheld or withdrawn: ____________________________.
Appointment of Health Care Proxy:
I designate the following individual as my health care proxy to make medical decisions on my behalf if I am unable to do so:
- Full Name of Proxy: ______________________________________
- Address: ___________________________________________
- Phone Number: ______________________________________
Signature:
By signing below, I affirm that I understand the contents of this Living Will and that I am signing it voluntarily.
Signature: ___________________________________________
Date: ______________________________________________
This Living Will must be witnessed by two individuals who are not related to me by blood or marriage and who will not inherit from me.