Okla. Stat. tit. 63 § 3131.5
FRONT PAGE OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM I, _________________________, request limited health care as described in this document. If my heart stops beating or if I stop breathing, no medical procedure to restore breathing or heart function will be instituted by any health care provider including, but not limited to, emergency medical services (EMS) personnel.
I understand that this decision will not prevent me from receiving other health care such as the Heimlich maneuver or oxygen and other comfort care measures.
I understand that I may revoke this consent at any time in one of the following ways:
I give permission for this information to be given to EMS personnel, doctors, nurses, and other health care providers. I hereby state that I am making an informed decision and agree to a do-not-resuscitate order.
________________ | OR | ________________ | |
Signature of Person | Signature of Representative | ||
(Limited to an attorney-in-fact for health care decisions acting under the Oklahoma Health Care Agent Act, a health care proxy acting under the Oklahoma Advance Directive Act or a guardian of the person appointed under the Oklahoma Guardianship and Conservatorship Act.) | |||
This DNR consent form was signed in my presence. | |||
________________ | ________________ | ________________ | |
Date | Signature of Witness | Address | |
________________ | ________________ | ||
Signature of Witness | Address | ||
BACK OF PAGE
CERTIFICATION OF PHYSICIAN
(This form is to be used by an attending physician only to certify that an incapacitated person without a representative would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. An attending physician of an incapacitated person without a representative must know by clear and convincing evidence that the incapacitated person, when competent, decided on the basis of information sufficient to constitute informed consent that such person would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. Clear and convincing evidence for this purpose shall include oral, written, or other acts of communication between the patient, when competent, and family members, health care providers, or others close to the patient with knowledge of the patient's desires.) I hereby certify, based on clear and convincing evidence presented to me, that I believe that ___________________________
Name of Incapacitated Person would not have consented to the administration of cardiopulmonary resuscitation in the event of cardiac or respiratory arrest.
Therefore, in the event of cardiac or respiratory arrest, no chest compressions, artificial ventilation, intubations, defibrillation, or emergency cardiac medications are to be initiated.
_________________________ | _________________________ |
Physician's Signature/Date | Physician's Name (PRINT) |
__________________________________________ | |
Physician's Address/Phone | |
Okla. Stat. tit. 63, § 3131.5