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Declaration Relating to Use of Life Sustaining

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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

Signed this day of , 20

The declarant voluntarily signed this writing in my presence.

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

Signed this day of , 20

The declarant voluntarily signed this writing in my presence.

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What this Declaration Is and When it Applies

A Declaration Relating to Use of Life Sustaining is a legally binding advance directive used to state an individual’s preferences about life-sustaining medical treatments such as cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition and hydration, and other extraordinary measures. The form lets a person specify conditions under which such treatments should or should not be administered, and may identify a healthcare agent to make decisions when the person lacks capacity. Requirements for signatures, witnesses, and notarization vary by state; the document should be completed while the signer is competent and able to express intent.

Why a Clear Declaration Matters

A clear Declaration documents patient intent, guides clinicians during critical care, reduces family conflict, and creates an enforceable record when completed correctly under applicable electronic signature and state laws such as ESIGN and UETA.

Why a Clear Declaration Matters

Who Typically Completes This Declaration

People planning for serious illness or end-of-life scenarios complete this form to record preferences and designate decision-makers.

  • Adults with chronic or terminal conditions who want specific treatment limits and appointed agents.
  • Family members and appointed healthcare agents who need authoritative guidance for critical medical decisions.
  • Hospitals, long-term care facilities, and clinicians seeking documented patient instructions to follow in an emergency.

Step-by-Step: Completing the Declaration

Complete the form in a calm setting, confirm capacity, and follow witness or notary rules to ensure legal validity.

  • 01
    Review options: Read treatment choices and examples before answering.
  • 02
    Name an agent: Designate a primary and alternate decision-maker.
  • 03
    Specify conditions: State the clinical situations that trigger your instructions.
  • 04
    Sign and validate: Sign, date, and obtain required witnesses or notarization.

Frequently Asked Questions and Practical Answers

Answers to common issues that arise when preparing, signing, and relying on a Declaration Relating to Use of Life Sustaining.


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Security and Compliance Considerations

Encryption in transit: TLS 1.2/1.3
Encryption at rest: AES-256
Audit trail: Timestamp and IP log
HIPAA support: BAA available
Regulatory standards: SOC 2 Type II
Access controls: Multi-factor options

Common Legal and Clinical Risks to Avoid

Improper witnessing: May invalidate the form
Ambiguous language: Leads to varied clinical interpretation
Unshared copies: Providers may not follow unwitnessed wishes
Outdated directives: May not reflect current intent
Privacy breaches: HIPAA violations risk fines
Agent conflict: Family disputes can delay care

Common Preparation Mistakes

  • Leaving treatment preferences vague or conditional without clear clinical triggers creates interpretive disputes and may cause clinicians to default to maximal treatment.
  • Failing to list contact details and alternates for the healthcare agent can prevent timely decisions when the primary agent is unavailable.
  • Skipping required witness or notary steps based on incorrect assumptions about state law risks invalidation and potential court involvement.
  • Not distributing signed copies to clinicians, the agent, and close family members reduces the chance the declaration will be located when urgently needed.

How to Distribute and Register Your Declaration

A completed declaration should be shared with medical providers, the chosen agent, and stored according to legal and clinical expectations so it can be retrieved during emergencies.

  • Give to provider: Provide a signed copy to your primary clinician.
  • Register if available: File with state registry or health system repository.
  • Share with agent: Give agent original or certified copy.
  • Retain original: Keep original in secure but accessible location.

Digital Signing and Technical Requirements

When completing or e-signing the declaration online, ensure the platform supports legal evidence capture, secure storage, and required authentication.

  • File formats: PDF, DOCX supported
  • Integrations: Connects to major EHRs and storage
  • Authentication: Email, SMS, or stronger options

How This Declaration Differs from Related Documents

Compare the Declaration Relating to Use of Life Sustaining with other advance-care instruments to choose the correct form for your situation.

Document Type Declaration Living Will DNR POLST
Purpose personal treatment choices end-of-life wishes withhold cpr medical order for clinicians
Formality variable witness/notary variable clinician-signed clinician-signed
Portability high across settings high limited to hospital/ems medical order limited
Use case future incapacity planning end-stage preferences immediate resuscitation choice actionable medical orders

eSignature Pricing and Feature Comparison

Pricing and basic feature availability for common eSignature providers; signNow is listed first in accordance with comparison format requirements.

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 Varies by vendor Varies by vendor Varies by vendor Varies by vendor
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 Varies Varies

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