Fill and Sign the 50 9 103 Declaration Relating to Use of Life Sustaining Form

HEALTH CARE DECLARATION(incurable or irreversible condition) If I should have an incurable or irreversible condition 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 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] [follow the instructions of _____________________________________ whom I appoint as my Health Care Proxy to decide whether life-sustaining treatment should be withheld or withdrawn]. It is my specific directive that nutrition may be withheld after consultation with my attending physician. It is my specific directive that hydration may be withheld after consultation with my attending physician. It is my specific directive that nutrition may not be withheld. It is my specific directive that hydration may not be withheld. Signed this day of , 20 . Signature _____________________________________Address _____________________________________ The declarant voluntarily signed this writing in my presence. Witness ______________________________________ Address _____________________________________ Witness ______________________________________ Address _____________________________________ HEALTH CARE DECLARATION (if unconscious) 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] [follow the instructions of _____________________________________ whom I appoint as my health care proxy to decide whether life-sustaining treatment should be withheld or withdrawn]. It is my specific directive that nutrition may be withheld after consultation with my attending physician. It is my specific directive that hydration may be withheld after consultation with my attending physician. It is my specific directive that nutrition may not be withheld. It is my specific directive that hydration may not be withheld. Signed this day of , 20 . Signature ____________________________________Address _____________________________________ The declarant voluntarily signed this writing in my presence. Witness ______________________________________ Address _____________________________________ Witness ______________________________________ Address _____________________________________