Okla. Stat. tit. 63, § 63-3101.4

nutrition/hydration provision - Form - Inclusion in declarant's

medical records - Authority of proxy - Designation based on

religious beliefs or tenets.

A. An individual of sound mind and eighteen (18) years of age

or older may execute at any time an advance directive for health

care governing the provision, withholding, or withdrawal of life-

sustaining treatment. The advance directive shall be signed by the

declarant and witnessed by two individuals who are eighteen (18)

years of age or older who are not legatees, devisees, or heirs at

law.

B. An advance directive that is not in the form set forth in

subsection C of this section and that is executed in Oklahoma shall

not be deemed to authorize the withholding or withdrawal of

artificially administered nutrition and/or hydration unless it

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specifically authorizes the withholding or withdrawal of

artificially administered nutrition and/or hydration in the

declarant’s own words or by a separate section, separate paragraph,

or other separate subdivision that deals only with nutrition and/or

hydration and which section, paragraph, or other subdivision is

separately initialed, separately signed, or otherwise separately

marked by the declarant.

C. An advance directive may be in substantially the following

form:

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.

I. Living Will

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:

(1) If I have a terminal condition, that is, an incurable

and irreversible condition that even with the

administration of life-sustaining treatment will, in

the opinion of the attending physician and another

physician, result in death within six (6) months:

____ 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.

Initial only ____ I direct that my life not be extended by

one option 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)

(2) If I am persistently unconscious, that is, I have

an irreversible condition, as determined by the

attending physician and another physician, in

which thought and awareness of self and

environment are absent:

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_____ 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.

Initial only _____ I direct that my life not be extended by

one option 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)
life not be extended by

one option 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)

(3) If I have an end-stage condition, that is, a

condition caused by injury, disease, or illness,

which results in severe and permanent deterioration

indicated by incompetency and complete physical

dependency for which treatment of the irreversible

condition would be medically ineffective:

_____ 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.

Initial only _____ I direct that my life not be extended by

one option 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

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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)

(4) OTHER. Here you may:

(a) describe other conditions in which you would

want life-sustaining treatment or

artificially administered nutrition and

hydration provided, withheld, or withdrawn,

(b) give more specific instructions about your

wishes concerning life-sustaining treatment

or artificially administered nutrition and

hydration if you have a terminal condition,

are persistently unconscious, or have an

end-stage condition, or

(c) do both of these:

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_________________________________________________

_______

Initial

II. My Appointment of My Health Care Proxy

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.

III. Anatomical Gifts

Pursuant to the provisions of the Uniform Anatomical Gift Act, I

direct that at the time of my death my entire body or designated

body organs or body parts be donated for purposes of:

(Initial all that apply)

_____ transplantation

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_____ 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
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

IV. General Provisions

a. I understand that I must be eighteen (18) years of age

or older to execute this form.

b. I understand that my witnesses must be eighteen (18)

years of age or older and shall not be related to me

and shall not inherit from me.

c. I understand that if I have been diagnosed as pregnant

and that diagnosis is known to my attending physician,

I will be provided with life-sustaining treatment and

artificially administered hydration and nutrition

unless I have, in my own words, specifically

authorized that during a course of pregnancy, life-

sustaining treatment and/or artificially administered

hydration and/or nutrition shall be withheld or

withdrawn.

d. In the absence of my ability to give directions

regarding the use of life-sustaining procedures, it is

my intention that this advance directive shall be

honored by my family and physicians as the final

expression of my legal right to choose or refuse

medical or surgical treatment including, but not

limited to, the administration of life-sustaining

procedures, and I accept the consequences of such

choice or refusal.

e. This advance directive shall be in effect until it is

revoked.

f. I understand that I may revoke this advance directive

at any time.

g. I understand and agree that if I have any prior

directives, and if I sign this advance directive, my

prior directives are revoked.

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h. I understand the full importance of this advance

directive and I am emotionally and mentally competent

to make this advance directive.

i. I understand that my physician(s) shall make all

decisions based upon his or her best judgment applying

with ordinary care and diligence the knowledge and

skill that is possessed and used by members of the

physician’s profession in good standing engaged in the

same field of practice at that time, measured by

national standards.

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

___________________________, Oklahoma

Residence

___________________________________

Witness

___________________________, Oklahoma

Residence

D. A physician or other health care provider who is furnished

the original or a photocopy of the advance directive shall make it a

part of the declarant's medical record and, if unwilling to comply

with the advance directive, promptly so advise the declarant.

E. In the case of a qualified patient, the patient's health

care proxy, in consultation with the attending physician, shall have

the authority to make treatment decisions for the patient including

the provision, withholding, or withdrawal of life-sustaining

procedures if so indicated in the patient's advance directive.

F. A person executing an advance directive appointing a health

care proxy who may not have an attending physician for reasons based

on established religious beliefs or tenets may designate an

individual other than the designated health care proxy, in lieu of
t including

the provision, withholding, or withdrawal of life-sustaining

procedures if so indicated in the patient's advance directive.

F. A person executing an advance directive appointing a health

care proxy who may not have an attending physician for reasons based

on established religious beliefs or tenets may designate an

individual other than the designated health care proxy, in lieu of

an attending physician and other physician, to determine the lack of

decisional capacity of the person. Such designation shall be

specified and included as part of the advance directive executed

pursuant to the provisions of this section.

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