Declaration Of Living Will Form, Durable Power Of Attorney For Health Care Template (Page 2 of 4) in pdf

Declaration Of Living Will Form, Durable Power Of Attorney For Health Care Template Page 2

DECLARATION OF LIVING WILL

_________________________________

[Name of Declarant]

If I should have an incurable or irreversible condition with no hope of recovery that will cause my

death within a relatively short time, and I am no longer able to make decisions regarding my medical

treatment, I direct my attending physician, pursuant to the Common Law and the Arkansas Rights of the

Terminally Ill or Permanently Unconscious Act, to withhold or withdraw treatment that only prolongs the

process of dying and is not necessary to my comfort or to alleviate pain.

Additionally, if I should become permanently unconscious, I direct my attending physician,

pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, to withhold or

withdraw life-sustaining treatments that are no longer necessary to my comfort or to alleviate pain.

Section 1:

Life-Sustaining Treatments

The life-sustaining treatments which may be withheld or withdrawn are (check all that apply):

Cardiopulmonary Resuscitation.

Mechanical Breathing.

Major Surgery.

Kidney Dialysis.

Chemotherapy.

Minor Surgery (unless necessary for my comfort or to alleviate pain).

Invasive Diagnostic Tests.

Antibiotics.

Blood Products.

Other Medications not Necessary for Alleviation of Pain.

Add other medical directives, if any________________________________________________

___________________________________________________________________________________

__________________________________________________________________________________

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