Declaration Of Living Will Form
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1
2DECLARATION OF LIVING WILL
OF
_________________________________
[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The life-sustaining treatments which may be withheld or withdrawn are (check all that apply):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.
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Mechanical Breathing.
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Major Surgery.
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Kidney Dialysis.
!
Chemotherapy.
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Minor Surgery (unless necessary for my comfort or to alleviate pain).
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Invasive Diagnostic Tests.
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Antibiotics.
!
Blood Products.
!
Other Medications not Necessary for Alleviation of Pain.
Add other medical directives, if any________________________________________________
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