Power of Attorney for Health Care - Arkansas

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WHEN MY DEATH IS IMMINENT
A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a
reasonably prudent physician, knowledgeable about the case and the treatment possibilities with
respect to the medical conditions involved, would judge that I will live only a week or less even
if lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
(Cross off any remaining blank lines.)
WHEN I AM TERMINALLY ILL
B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even
though death is not imminent I am in the final stage of that terminal condition – meaning that a
reasonably prudent physician, knowledgeable about the case and the treatment possibilities with
respect to the medical conditions involved, would judge that I will live only three months or less,
even if lifesaving treatment or care is provided to me – the following may be withheld or
withdrawn:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
C. OTHER SPECIAL CONDITIONS:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
Page 3/4
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Power of Attorney for Health Care - Arkansas PDF

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