“DECLARATION “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 physi- cian, pursuant to the Arkansas Rights of the Terminally Ill or Perma- nently 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 whom I appoint as my Health Care Proxy to decide whether life-sustaining treatment should be withheld or withdrawn]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 consul- tation with my attending physician

It is my specific directive that hydration may be withheld after consul- tation 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 ............................................................................................

I am a competent adult who is not named as a healthcare proxy in this document. I witnessed the patient’s signature on this form

Witness ............................................................................................

Address ............................................................................................

I am a competent adult who is not named as a healthcare proxy in this document. I am not related to the patient by blood, marriage, or adoption and I would not be entitled to any portion of the patient’s estate upon his or her death under any existing will or codicil or by operation of law. I witnessed the patient’s signature on this form

Witness ............................................................................................

Address ............................................................................................”