DURABLE POWER OF ATTORNEY FOR HEALTH CARE OF
___________________________
Pursuant to the Arkansas Healthcare Decisions Act (Ark. Code Ann. § 20-6-101 et seq.) (the
“Act”), I hereby designate and appoint ________________________________ as my agent, or
attorney-in-fact, whose phone number is __________________________, 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 following powers:
(a) To consent, refuse, or withdraw consent to any and all types of medical care,
treatment, surgical procedures, diagnostic procedures, medication, and the use of
mechanical or other procedures that affect any bodily function, including, but not
limited to, artificial respiration, nutritional support and hydration, and
cardiopulmonary resuscitation;
(b) To have access to medical records and information to the same extent that I
am entitled to, including the right to disclose the contents to others;
(c) To authorize my admission to or discharge, even against medical advice,
from any hospital, nursing home, residential care, assisted living or similar facility
or other healthcare facility;
(d) To contract on my behalf for any health care related service or facility on
my behalf, without my agent incurring personal financial liability for such
contracts;
(e) To select and discharge medical, social service, and other support personnel
responsible for my care;
(f) To authorize, or refuse to authorize, any medication or procedure intended
to relieve pain, even though such use may lead to physical damage, addiction, or
hasten the moment of, but not intentionally cause, my death;
(g) To take any other action necessary to do what I authorize here, including
but not limited to granting any waiver or release from liability required by any
hospital, physician, or other health care provider; signing any documents relating
to refusals of treatment or the leaving of a facility against medical advice; and
pursuing any legal action in my name, and at the expense of my estate, to force
compliance with my wishes as determined by my agent, or to seek actual or punitive
damages for the failure to comply.
This Power of Attorney for Health Care shall give my agent the authority to make decisions
about withholding or withdrawal of life-sustaining treatment, and nutrition and hydration,
according to my wishes expressed in my Living Will, Health Care Directive, and/or
Advance Care Plan, or if my wishes are unclear under the then existing circumstances of
my medical condition, then upon consideration of my best interest as determined by my
