Arkansas Advance Directive for Health Care

(Living Will & Optional Health-Care Proxy)

[// GUIDANCE: This template integrates (i) a Living Will (treatment instructions) and (ii) an optional Health-Care Proxy (agent appointment). Attorneys may delete Part II if a separate POA for health care will be used.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
   3.1 Statement of Intent
   3.2 Designation of Health-Care Agent (optional)
   3.3 Treatment Preferences
   3.4 Organ & Tissue Donation
   3.5 HIPAA Authorization
4. Representations & Warranties
5. Covenants & Continuing Obligations
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block (Signature, Witnesses, Notary)

1. DOCUMENT HEADER

Arkansas Advance Directive for Health Care
Date: [EFFECTIVE DATE]

This Advance Directive (“Directive”) is executed by [DECLARANT FULL LEGAL NAME], born [DATE OF BIRTH], residing at [ADDRESS] (“Declarant”), pursuant to the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, Ark. Code Ann. § 20-17-201 et seq. (the “Act”).

Declarant is of sound mind and executes this Directive voluntarily to govern future health-care decisions should Declarant become unable to communicate informed consent.

2. DEFINITIONS

For purposes of this Directive, capitalized terms have the meanings set forth below.

“Act” – the Arkansas Rights of the Terminally Ill or Permanently Unconscious Act, Ark. Code Ann. § 20-17-201 et seq.

“Advance Directive” or “Directive” – this instrument, including all parts, amendments, and copies thereof.

“Agent” – the person designated in Section 3.2 to make health-care decisions on Declarant’s behalf.

“Artificial Nutrition and Hydration” – medically administered food or fluids through tubes, IV, or similar means.

“Attending Physician” – the physician having primary responsibility for the care of Declarant.

“Health-Care Provider” – any person or facility licensed, certified, or otherwise authorized pursuant to Arkansas law to administer health care.

“Life-Sustaining Treatment” – any medical intervention or procedure serving only to postpone the moment of death, including without limitation cardiopulmonary resuscitation (CPR), ventilation, dialysis, and Artificial Nutrition and Hydration.

“Permanently Unconscious Condition” – an irreversible state in which Declarant is not aware of self or environment and has no reasonable expectation of regaining consciousness.

“Terminal Condition” – an incurable or irreversible condition that, without Life-Sustaining Treatment, will result in death within a relatively short time, as determined by the Attending Physician.

3. OPERATIVE PROVISIONS

3.1 Statement of Intent

Declarant directs that health-care decisions be made in accordance with this Directive when Declarant:
a) has a Terminal Condition; or
b) is in a Permanently Unconscious Condition;
and is incapable of communicating informed decisions.

3.2 Designation of Health-Care Agent (Optional)

1. Primary Agent: [PRIMARY AGENT NAME], residing at [ADDRESS], phone [PHONE].
2. Successor Agent(s) (in order of priority):
   a) [SUCCESSOR #1 NAME], phone [PHONE].
   b) [SUCCESSOR #2 NAME], phone [PHONE].
3. Scope of Authority: The Agent may make any health-care decision Declarant could make, including decisions regarding Life-Sustaining Treatment, pain relief, admission to or discharge from medical facilities, and post-mortem decisions under Section 3.4, subject to express limitations herein.
4. Limitations: [INSERT ANY LIMITATIONS OR “None.”]
   [// GUIDANCE: Arkansas law permits combination documents; delete this subsection if Declarant executes a separate Durable Power of Attorney for Health Care.]

3.3 Treatment Preferences

1. Terminal Condition
   If I have a Terminal Condition and lack capacity, my preference is:
   ☐ Withhold Life-Sustaining Treatment.
   ☐ Continue Life-Sustaining Treatment.
   ☐ Agent decides.
   [// GUIDANCE: Select one; attorneys should initial boxes or use plain-language statements.]

2. Permanently Unconscious Condition
   ☐ Withhold Life-Sustaining Treatment.
   ☐ Continue Life-Sustaining Treatment.
   ☐ Agent decides.

3. Artificial Nutrition and Hydration
   ☐ Withhold. ☐ Continue. ☐ Agent decides.

4. Pain Relief / Palliative Care
   Even if foregoing Life-Sustaining Treatment, I direct provision of medication or other palliative care necessary to alleviate pain or distress, even if such measures may hasten death.

5. Pregnancy Provision (Required if Declarant is or may become pregnant)
   If I am pregnant at the time decisions must be made, I direct:
   ☐ Overlay statutory requirement to preserve life of fetus if feasible.
   ☐ Follow my treatment preferences regardless of pregnancy.
   [// GUIDANCE: Arkansas law is silent on pregnancy override; include client’s preference and advise separate counseling.]

3.4 Organ & Tissue Donation

Upon death, I:
☐ Donate any needed organs or tissues for transplant, therapy, research, or education.
☐ Donate only the following: [SPECIFY].
☐ Decline donation.

3.5 HIPAA Authorization

Declarant authorizes any Health-Care Provider to disclose protected health information to the Agent and alternate agents named herein to facilitate decision-making, in compliance with 45 C.F.R. § 164.508.

4. REPRESENTATIONS & WARRANTIES

Declarant represents and warrants that:
a) Declarant is at least 18 years old and of sound mind;
b) Declarant understands the nature and import of this Directive;
c) Declarant has not been coerced or unduly influenced; and
d) All information provided is accurate as of the Effective Date.
These representations survive execution and remain binding.

5. COVENANTS & CONTINUING OBLIGATIONS

5.1 Declarant shall provide copies of this Directive to the Agent, successor agents, primary physician, and relevant Health-Care Providers.

5.2 Declarant covenants to review this Directive periodically and to execute updated instruments as personal preferences or the law evolve.

6. DEFAULT & REMEDIES

6.1 If any Health-Care Provider fails to honor this Directive, the Agent (or, if no Agent, any interested person) may seek injunctive relief compelling compliance.

6.2 Attorneys’ Fees: A prevailing party enforcing this Directive in good faith shall be entitled to reasonable attorneys’ fees and costs.

7. RISK ALLOCATION

7.1 Provider Protection
No Health-Care Provider acting in good faith and in reliance on this Directive shall incur civil or criminal liability or be subject to professional discipline for actions consistent with the Act.

7.2 Limitation of Liability
Declarant’s Agent shall not be liable for health-care costs incurred pursuant to good-faith decisions made under this Directive, except for willful misconduct or gross negligence.

8. DISPUTE RESOLUTION

This Directive shall be governed by the laws of the State of Arkansas without regard to conflict-of-laws principles. The state courts of Arkansas shall have exclusive jurisdiction over any action relating to its enforcement. Nothing herein waives the right to seek injunctive relief to prevent irreparable harm.

9. GENERAL PROVISIONS

9.1 Revocation
Declarant may revoke this Directive at any time by:
a) a signed, dated writing;
b) oral or other expression of intent to revoke in the presence of the Attending Physician; or
c) destroying or directing another to destroy this Directive.
Revocation is effective upon communication to the Attending Physician.

9.2 Amendment
Any amendment must be executed with the same formalities as this Directive.

9.3 Severability
If any provision is held invalid, the remaining provisions shall remain in full force.

9.4 Copies
A photocopy or electronically transmitted copy of this Directive has the same force as the original.

9.5 Integration
This Directive constitutes the entire statement of Declarant’s health-care instructions and supersedes all prior inconsistent documents.

10. EXECUTION BLOCK

10.1 Declarant Signature

I understand and accept the consequences of this Directive.

____ __
[DECLARANT NAME] Date

10.2 Witness Attestation

We declare that: (i) the Declarant is personally known to us, appears to be of sound mind, and signed or acknowledged this Directive in our presence; (ii) we are at least 18 years old; (iii) at least one of us is not related to the Declarant by blood or marriage and is not entitled to any portion of the Declarant’s estate; (iv) we are not financially responsible for the Declarant’s medical care; and (v) we are not employees of a Health-Care Provider currently treating the Declarant.

[// GUIDANCE: Arkansas requires two witnesses satisfying the above disinterested-witness criteria. Notarization is optional but recommended.]

10.3 Notary Acknowledgment (Optional)

State of Arkansas )
County of [COUNTY] )

On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [DECLARANT NAME], known to me or satisfactorily proven to be the person whose name appears on this Directive, and acknowledged that he/she executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seal.

Notary Public
My commission expires: ____

[// GUIDANCE: Review for consistency with client’s existing estate-planning documents. File a copy with the Arkansas Secretary of State’s Advance Directive Registry if desired.]