Arkansas Medical Power of Attorney Form

The Arkansas medical power of attorney form is a document that is also known as “advanced directives.” Advanced Directives are specific instructions to health care providers, prepared in advance of a specific circumstance or condition, that states the care or treatment a person will receive when the specific circumstance or condition occurs. This document may also name a person as having the authority to make medical decisions on behalf of the principal when the specific condition or circumstance occurs. That person is commonly known as a surrogate, an attorney in fact or an agent. The most common conditions or circumstances are when the principal has a terminal illness and is expected to die in a small amount of time or if the principal is permanently unconscious, and they are unable to make his or her own medical decisions in the opinion of the treating physician. As of Jan.1, 2012, all powers of attorney in the state of Arkansas are considered durable unless otherwise stated in the document, so do make special instructions if you wish to choose to have a more limited power, created. (See Ark. Code Ann. 28-68-101 and § 20- 13-104).

How To Write

Step 1 – Begin by downloading the form provided. First two paragraphs. Be certain to read this information carefully as it may not contain all of the choices you would like to include. If you would like a more extensive power of attorney, you may choose to consult with an attorney or you may add sheet(s) to be attached to this form with more information with regard to your wishes.

Step 2 – Life Sustaining Treatments – This section will address any life sustaining treatments that you would like to have withheld or withdrawn in the event you are nearing an end of life situation. Check the boxes in front of any of the treatments that would apply. If you would not like to have any of the stated treatments withdrawn or withheld simply leave the box unchecked. If you do not understand the terms as outlined, you will find their definitions on page 3 ask an attorney, social worker, physician or family member to assist you in understanding the terms and your rights.

  • 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

Step 2 – Additional Medical Directives – In this section, on the lines provided on the form, you would add any additional medical directives you would like to have honored at the end of your life. If you would like to have your life preserved at all costs, do not check any of the boxes above the lines and state specifically what you would like to have anyone acting on your behalf do, to ensure that all of your decisions are followed exactly as you would like them to be. Complete the lines on the form. If you need more room, add sheets to attach to this form.

Step 3 – Artificial Nutrition and Hydration – The state of Arkansas requires that you separately decide what your wishes are with regard to nutrition and hydration. This section will ask that you initial the line before the following statements if you wish to have nutrition and/or hydration withheld if death is imminent.

  • DIRECT that artificial nutrition may be withheld or withdrawn after consultation with my attending physician
  • DIRECT that artificial hydration may be withheld or withdrawn after consultation with my attending physician

Step 4 – In order to validate these wishes, you must sign this section with two witnesses.

  • Provide the date (in dd/mm/yyyy format)
  • Provide the signature of the principal on the signature line
  • The witnesses must both provide the following in the witness sections provided
  • Both witnesses must read the information in the paragraph and agree. Then provide –
  • Witness’ Signature
  • Physical Address
  • City
  • State
  • Zip Code

Step 5 – Delegation of an Attorney in Fact/agent – The next section, beginning on page 3 will allow you to designate someone you trust to follow your directives and help make decisions when you are no longer able to do so on your own. Provide the following information:

  • Provide the Declarant (Principal) at the top of the page.
  • In the next line inside the paragraph, place the name of the person you would like to have act on your behalf in the event you are no longer able to do so
  • In the next paragraph, should you as the principal so desire, you may enter the name of a secondary person also known as a successor attorney in fact, to assist with your decisions with regard to your life choices in the event the original attorney in fact is, for any reason, unable or unwilling to carry out your wishes. Place their name in the paragraph addressing who your successor would be. This is optional, but should be considered.
  • Again, you will require two adult witnesses to verify and sign this section of the document. Provide the the witness information as follows:
  • Signature of witnesses on their respective lines
  • physical addresses
  • City
  • State
  • Zip Codes

Step 6 – Once your directives are complete, you may then have copies made. Provide copies to:

  • Your attorney in fact/agent
  • Your successor attorney in fact/agent
  • All witnesses who have signed the forms
  • Your physicians
  • Your attorney (if any)