Advance Directive for Health Care
If I am incapable of making an informed decision regarding my health care, I direct my health care providers to follow my instructions below.
If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers, pursuant to the Oklahoma Advance Directive Act, to follow my instructions as set forth below:
Initial only one option | _____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. |
_____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration. | |
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. | |
_____ See my more specific instructions in paragraph (4) below. (Initial if applicable) |
Initial only one option | _____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. |
_____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration. | |
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. | |
_____ See my more specific instructions in paragraph (4) below. (Initial if applicable) |
Initial only one option | _____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. |
_____ I direct that my life not be extended by life-sustaining treatment, including artificially administered nutrition and hydration. | |
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by mouth, I wish to receive artificially administered nutrition and hydration. | |
_____ See my more specific instructions in paragraph (4) below. (Initial if applicable) |
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_______Initial
If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers pursuant to the Oklahoma Advance Directive Act to follow the instructions of _______________, whom I appoint as my health care proxy. If my health care proxy is unable or unwilling to serve, I appoint ______________ as my alternate health care proxy with the same authority. My health care proxy is authorized to make whatever medical treatment decisions I could make if I were able, except that decisions regarding life-sustaining treatment and artificially administered nutrition and hydration can be made by my health care proxy or alternate health care proxy only as I have indicated in the foregoing sections.
If I fail to designate a health care proxy in this section, I am deliberately declining to designate a health care proxy.
(Initial all that apply)
_____ transplantation
_____ therapy
_____ advancement of medical science, research, or education
_____ advancement of dental science, research, or education
Death means either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem. If I initial the "yes" line below, I specifically donate:
_____ | My entire body | ||
or | |||
_____ | The following body organs or parts: | ||
_____ | lungs | _____ | liver |
_____ | pancreas | _____ | heart |
_____ | kidneys | _____ | brain |
_____ | skin | _____ | bones/marrow |
_____ | blood/fluids | _____ | tissue |
_____ | arteries | _____ | eyes/cornea/lens |
Signed this _____ day of __________, 20 _____.
___________________________________(Signature)
___________________________________City of
___________________________________County, Oklahoma
___________________________________Date of birth
_______________________________________(Optional for identification purposes)
This advance directive was signed in my presence.
___________________________________Witness
___________________________, OklahomaResidence
___________________________________Witness
___________________________, OklahomaResidence
Okla. Stat. tit. 63, § 3101.4