Who can legally sign this declaration?

An adult with capacity may sign. Capacity is assessed by a clinician; if the declarant later becomes incapacitated, the form applies under the conditions stated. If capacity is in doubt at signing, consult counsel or obtain physician documentation.

Are witnesses or notarization required?

Requirements vary by state. Many states require two witnesses or a notary; others accept an unsigned form recorded in medical records. Check your state's statutory form language. A self-proving notarization can reduce the need for future witness testimony.

Can I sign electronically or remotely?

Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA, but some jurisdictions or specific document types may have exceptions. Verify whether your state accepts e-signatures and remote notarization for advance directives and follow required witness or notarization rules.

How do I revoke or change my declaration?

You can revoke by executing a signed and dated revocation, creating a new declaration, or physically destroying the original; notify healthcare agents and providers. State law may prescribe specific revocation formalities—check statutory requirements.

What if this conflicts with another document?

A later-dated valid directive usually controls. Durable healthcare powers of attorney may interact with living wills; expressly state precedence if desired. When conflicts arise, providers and courts evaluate execution dates, statutory compliance, and clear evidence of intent.

How should I store and share the document securely?

Keep originals with medical records or a designated agent, provide copies to key providers, and store encrypted electronic copies with access controls and audit logs. Use HIPAA-compliant channels when sharing protected health information and ensure authorized access for clinicians during emergencies.

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Statutory Living Will Declaration

Statutory Living Will Declaration

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DECLARATION OF LIVING WILL OF

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:

Section 2: Artificial Nutrition and Hydration

I understand that Arkansas law requires me to make my wishes regarding artificial nutrition and hydration known separately from the above directions. Therefore, by initialing the appropriate line(s) below, I specifically:

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.

SIGNED this day of

We, the undersigned, do hereby certify that the Declarant, subscribed this Declaration of Living Will in our presence, and we, at his or her request, in his or her presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue influence, fraud or restraint and that his or her signature was voluntary.

Witness

Address

City, State and Zip Code

Witness

Address

City, State and Zip Code

DURABLE POWER OF ATTORNEY FOR HEALTH CARE OF

Ann. Pursuant to the Arkansas Durable Power of Attorney for Health Care Act (Ark. Code § 20-13-104) (the "Act"), I hereby designate and appoint as my agent, or attorney in fact, to make decisions regarding my health care during periods when my health care provider has determined that I lack capacity to decide for myself. Specifically, and not to limit any other rights prescribed under the Act, my attorney-in-fact shall have the power to have access to my medical records for treatment or payment decisions; to disclose medical records to others for purposes of treatment, payment, or health care operations; to employ and discharge physicians; to consent to or refuse to consent to medical procedures, including the withholding or withdrawal of life-sustaining treatment, and nutrition and hydration, according to my wishes expressed in my Living Will, or, if my wishes are unclear under the then existing circumstances of my medical condition, then upon consideration of my best interests as determined by my physician in consultation with my agent; to admit me to hospitals, including psychiatric hospitals, nursing homes, or hospice care; and to sign all appropriate forms, consents and releases in connection with any of said matters.

If resigns, or is not able or available to make health care decisions for me, or if an agent named by me is divorced from me or is my spouse and legally separated from me, I appoint as successor, with all of the rights and powers and authority herein stated. The term “health care” shall have the meaning set forth in Ark. Code Ann. § 20-13-104(c). This Durable Power of Attorney for Health Care shall not be affected by my subsequent disability or incapacity.

SIGNED this day of

We, the undersigned, do hereby certify that the Declarant, subscribed this Durable Power of Attorney for Health Care in our presence, and we, at his or her request, in his or her presence, and in the presence of each other, signed as attesting witnesses, and we do further certify that the Declarant appeared to be eighteen years of age or older, of sound mind, and acting without undue influence, fraud or restraint and that his or her signature was voluntary.

Witness

Address

City, State and Zip Code

Witness

Address

City, State and Zip Code

What a Statutory Living Will Declaration Is

A Statutory Living Will Declaration is a legally recognized advance directive that allows an adult to record instructions about life-sustaining medical treatment in the event they are incapacitated and unable to communicate. It typically states whether to accept or refuse CPR, mechanical ventilation, tube feeding, dialysis, or other life-prolonging measures under specified conditions. Many states provide a statutory form with standard language to ensure uniform interpretation by healthcare providers. The declaration becomes effective when a physician determines the declarant lacks decision-making capacity and the conditions specified in the form are met.

Why a Statutory Form Matters

Use a Statutory Living Will Declaration to ensure your treatment preferences are clear, legally documented, and accessible to clinicians and family. A statutory form reduces ambiguity, aligns with state law, and can simplify hospital decision-making when you cannot communicate your wishes.

Who Typically Prepares and Uses This Declaration

Common users of a Statutory Living Will Declaration include individuals planning for incapacity, family members, and healthcare representatives.

Adults age 18+ who wish to record end-of-life treatment preferences.
Designated healthcare agents or surrogates preparing to clarify authority under medical emergencies.
Attorneys and clinicians using the statutory format for consistent interpretation and portability.

Essential Sections Included in a Professional Declaration

A professional Statutory Living Will Declaration contains standardized sections to document identity, specific treatment choices, activation criteria, and the signatures and attestations required by state law.

Declarant ID

Full legal name, date of birth, address, and any identifying numbers should be recorded precisely to avoid ambiguity and ensure the declaration is attributable to the correct individual under supervising medical records.

Treatment Preferences

Explicit statements about accepting or refusing CPR, mechanical ventilation, artificial nutrition, dialysis, antibiotic use, and other life-sustaining treatments must be clear and specific to guide clinical decisions.

Activation Criteria

Specify the medical conditions or diagnostic criteria that will trigger the declaration, such as terminal illness, permanent unconsciousness, or irreversible coma, and whether multiple physician confirmations are required.

Physician Attestation

A treating physician should certify that the activation conditions are met and document clinical findings; the attestation enables healthcare institutions to apply the directive appropriately.

Witness/Notary

Include witness signature blocks or a notary acknowledgment as required by state law; some states permit two witnesses while others require notarization for self-proving status.

Revocation Clause

Instructions for revoking or amending the declaration should be included, indicating how to revoke (written notice, new declaration, physical destruction) and notifying clinicians and agents.

Step-by-Step: Completing the Declaration

Follow these steps to complete a Statutory Living Will Declaration accurately and in line with state requirements.

01

Review Form: Confirm the statutory language matches your state's form.
02

Complete Fields: Enter full name, DOB, address, and directives.
03

Sign With Witnesses: Sign in presence of required witnesses or notary.
04

Provide Copies: Distribute to agent, family, and healthcare providers.

Where to Send the Signed Declaration

After signing, route the declaration to clinicians, the named agent, and relevant medical records departments for availability during care.

Hospital Records: Give a copy to admitting medical records department.
Primary Care: Provide your primary care clinician with a signed copy.
Named Agent: Give agent original or certified copy for decision-making.
Emergency Wallet: Carry a concise card noting declaration and location of original.

Digital Signing and Integration Requirements

Digital signing and eSubmission for the Statutory Living Will Declaration require secure formats, appropriate authentication, and integration with medical records and legal workflows.

File Formats: PDF, PDF/A, and Word DOCX supported.
Integrations: Salesforce, Microsoft 365, NetSuite, Google Workspace
Authentication: Email, SMS code, KBA, SSO options

Timing Considerations and Typical Processing Times

Key timing considerations for executing, updating, and distributing a Statutory Living Will Declaration to ensure it remains valid and accessible.

Execution Effective Date:

Declares effective when physician determines incapacity per form criteria.

Review Frequency:

Review every 1–5 years or after major health or legal changes.

Distribution Timeline:

Provide copies to agents and providers immediately after signing.

Processing by Hospital:

Hospitals typically place directive in medical record within 24–72 hours.

Amendment Timing:

To amend, execute a new declaration and notify providers promptly.

Common Preparation Mistakes to Avoid

Using nonstatutory language that conflicts with the prescribed form, which can result in inconsistent interpretation by clinicians or rejection by hospital counsel.
Failing to obtain required witness signatures or notarization where the state statute requires them, making the declaration vulnerable to challenge when presented.
Not providing a clear effective date or conditions for activation, leading to disputes about whether the declarant was incapacitated at a given time.
Leaving contradictory advance directives or unsigned amendments in file, creating confusion about which document reflects the declarant's current wishes.

Risks and Legal Consequences of Improper Execution

Invalid Execution: May be unenforceable without required witnesses

Conflicting Documents: Later power of attorney may override

Outdated Preferences: Medical advances change treatment options

Incorrect Signer: Wrong name can trigger probate review

Missing Physician Cert: No activation without medical determination

Privacy Exposure: Improper handling risks HIPAA violations

Illustrative Cases: How Statutory Declarations Work

Real-world examples show how statutory declarations function in clinical and legal settings and why execution steps matter.

Hospital Use

A 68-year-old patient completed a state statutory living will in advance of major surgery, specifying refusal of prolonged mechanical ventilation.

Treating physician attestation activated directive.
Hospital staff located the signed original in medical records, honored the directive after two specialists confirmed prognosis, and the agent coordinated palliative care consistent with the patient's clear, documented preferences, avoiding unwanted aggressive interventions.

Probate Snapshot

An estate attorney used a notarized statutory living will to resolve a dispute over end-of-life care when family members disagreed about treatment.

The self-proving notarized form reduced witness testimony requirements.
Because the declaration followed state-prescribed language and included notarization, the probate court accepted it without live witness testimony, allowing the executor and medical team to implement the declarant's instructions promptly and with legal certainty.

Who Has Authority to Sign and Act

Declarant — Patient

Must be an adult with capacity at signing. The declarant must demonstrate understanding and intent; signing confirms that the stated preferences reflect the declarant's informed choices. If incapacity later occurs, healthcare providers use this directive to guide treatment consistent with the declarant's expressed wishes.

Healthcare Agent

A named agent (durable healthcare proxy) may make decisions only as authorized by the declaration and state law. Their role activates when the declarant lacks capacity. Agents are expected to follow the declared preferences and consult medical teams accordingly.

Supporting Documents and Export Options

Supporting documents and export options help clinicians and legal teams access and preserve the Statutory Living Will Declaration in appropriate formats.

Supporting Docs

Attach a durable power of attorney for healthcare, prior advance directives, and relevant medical summaries to provide context; include a copy of identification to support identity verification during activation.

PDF Export

Save a signed PDF/A copy for long-term archival; ensure embedded signatures and audit trails are preserved for admissibility and future verification.

Signed Copies

Provide certified paper copies when required by providers; retain an original notarized document if your state recognizes self-proving affidavits for wills-equivalent status.

Electronic Archive

Store encrypted electronic copies with access controls and audit logs; include metadata indicating signer, timestamp, and witnessing to support authenticity.

eSignature Pricing and Feature Comparison

Comparison of typical eSignature plan features and starting prices to help evaluate platform fit for managing Statutory Living Will Declarations.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Free trial available	Free trial available	Free trial available	Free trial available
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

FAQs and Troubleshooting

Answers to frequently asked questions about completing, signing, and using a Statutory Living Will Declaration, including identity, witnesses, and digital signing considerations.

Need help? Contact support

Who can legally sign this declaration?
An adult with capacity may sign. Capacity is assessed by a clinician; if the declarant later becomes incapacitated, the form applies under the conditions stated. If capacity is in doubt at signing, consult counsel or obtain physician documentation.
Are witnesses or notarization required?
Requirements vary by state. Many states require two witnesses or a notary; others accept an unsigned form recorded in medical records. Check your state's statutory form language. A self-proving notarization can reduce the need for future witness testimony.
Can I sign electronically or remotely?
Electronic signatures are generally valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA, but some jurisdictions or specific document types may have exceptions. Verify whether your state accepts e-signatures and remote notarization for advance directives and follow required witness or notarization rules.
How do I revoke or change my declaration?
You can revoke by executing a signed and dated revocation, creating a new declaration, or physically destroying the original; notify healthcare agents and providers. State law may prescribe specific revocation formalities—check statutory requirements.
What if this conflicts with another document?
A later-dated valid directive usually controls. Durable healthcare powers of attorney may interact with living wills; expressly state precedence if desired. When conflicts arise, providers and courts evaluate execution dates, statutory compliance, and clear evidence of intent.
How should I store and share the document securely?
Keep originals with medical records or a designated agent, provide copies to key providers, and store encrypted electronic copies with access controls and audit logs. Use HIPAA-compliant channels when sharing protected health information and ensure authorized access for clinicians during emergencies.

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