Okla. Stat. tit. 63, § 63-3105.4

1. At the top of the first page of the standardized format

Oklahoma physician orders for life-sustaining treatment form the

following wording in all capitals shall appear against a contrasting

color background: "FORM SHALL ACCOMPANY PERSON WHEN TRANSFERRED OR

DISCHARGED"; at the bottom of the first page the following wording

in all capitals shall appear against a contrasting color background:

"HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AND PROXY

DECISION MAKERS AS NECESSARY FOR TREATMENT".

2. There shall be an introductory section, the left block of

which shall contain the name "Oklahoma Physician Orders for Life-

Sustaining Treatment (POLST)" followed by the words, "This Physician

Order set is based on the patient's current medical condition and

wishes and is to be reviewed for potential replacement in the case

of a substantial change in either, as well as in other cases listed

under F. Any section not completed indicates full treatment for

that section. Photocopy or fax copy of this form is legal and

valid." and the right block of which shall contain lines for the

patient's name, the patient's date of birth and the effective date

of the form followed by the statement, "Form must be reviewed at

least annually."

3. In Section A of the form, the left block shall contain, in

bold font, "A. Check One", and the right block shall be headed, in

bold font, "Cardiopulmonary Resuscitation (CPR): Person has no

pulse and is not breathing." below which there shall be a checkbox

followed by "Attempt Resuscitation (CPR)", then a checkbox followed

by "Do Not Attempt Resuscitation (DNR/ no CPR)", and below which

shall be the words, "When not in cardiopulmonary arrest, follow

orders in B, C and D below."

4. In Section B of the form, the left block shall contain, in

bold, "B. Check One", and the right block shall be headed, in bold,

"Medical Interventions: Person has pulse and/or is breathing."

Below this there shall be a checkbox followed by, in bold, "Full

Treatment" followed by, "Includes the use of intubation, advanced

airway interventions, mechanical ventilation, defibrillation or

cardio version as indicated, medical treatment, intravenous fluids,

and cardiac monitor as indicated. Transfer to hospital if

indicated. Include intensive care. Includes treatment listed under

"Limited Interventions" and "Comfort Measures", followed by, in

bold, "Treatment Goal: Attempt to preserve life by all medically

effective means."

Below this there shall be a checkbox followed by, in bold,

"Limited Interventions" followed by, "Includes the use of medical

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treatment, oral and intravenous medications, intravenous fluids,

cardiac monitoring as indicated, noninvasive bi-level positive

airway pressure, a bag valve mask or other advanced airway

interventions. Includes treatment listed under "Comfort Measures",

followed by, "Do not use intubation or mechanical ventilation.

Transfer to hospital if indicated. Avoid intensive care." followed

by, in bold, "Treatment Goal: Attempt to preserve life by basic

medical treatments."

Below this there shall be a checkbox followed by, in bold,

"Comfort Measures only" followed by, "Includes keeping the patient

clean, warm and dry; use of medication by any route; positioning,

wound care and other measures to relieve pain and suffering. Use

oxygen, suction and manual treatment of airway obstruction as needed

for comfort. Transfer from current location to intermediate

facility only if needed and adequate to meet comfort needs and to

hospital only if comfort needs cannot otherwise be met in the

patient's current location (e.g., hip fracture; if intravenous route

of comfort measures is required)."

Below this there shall be, in italics, "Additional Orders:"

followed by an underlined space for other instructions.

5. In Section C of the form, the left block shall contain, in
f needed and adequate to meet comfort needs and to

hospital only if comfort needs cannot otherwise be met in the

patient's current location (e.g., hip fracture; if intravenous route

of comfort measures is required)."

Below this there shall be, in italics, "Additional Orders:"

followed by an underlined space for other instructions.

5. In Section C of the form, the left block shall contain, in

bold, "C. Check One" and the right block shall be headed, in bold,

"Antibiotics".

Below this there shall be a checkbox followed by, in bold, "Use

antibiotics to preserve life."

Below this there shall be a checkbox followed by, in bold,

"Trial period of antibiotics if and when infection occurs." After

this there shall be, in italics, "*Include goals below in E."

Below this there shall be a checkbox followed by, in bold,

"Initially, use antibiotics only to relieve pain and discomfort."

After this there shall be, in italics, "+Contact patient or

patient's representative for further direction."

Below this there shall be, in italics, "Additional Orders:"

followed by an underlined space for other instructions.

6. In Section D of the form, the left block shall contain, in

bold, "D. Check One in Each Column", and the right block shall be

headed in bold, "Assisted Nutrition and Hydration", below which

shall be "Administer oral fluids and nutrition, if necessary by

spoon feeding, if physically possible." Below these the right block

shall be divided into three columns.

The leftmost column shall be headed, "TPN (Total Parenteral

Nutrition-provision of nutrition into blood vessels)." Below this

there shall be a checkbox followed by, in bold, "TPN long-term"

followed by "if needed". Below this there shall be a checkbox

followed by, in bold, "TPN for a trial period*". Below this there

shall be a checkbox followed by, in bold, "Initially, no TPN+".

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The middle column shall be headed "Tube Feeding". Below this

there shall be a checkbox followed by, in bold, "Long-term feeding

tube" followed by "if needed". Below this there shall be a checkbox

followed by, in bold, "Feeding tube for a trial period*". Below

this there shall be a checkbox followed by, in bold, "Initially, no

feeding tube".

The rightmost column shall be headed, "Intravenous (IV) Fluids

for Hydration". Below this there shall be a checkbox followed by,

in bold, "Long-term IV fluids" followed by "if needed". Below this

there shall be a checkbox followed by, in bold, "IV fluids for a

trial period*". Below this there shall be a checkbox followed by,

in bold, "Initially, no IV fluids+".

Running below all the columns there shall be, in italics,

"Additional Orders:" followed by an underlined space for other

instructions, followed by, in italics, "*Include goals below in E.

+Contact patient or patient's representative for further direction."

7. In Section E of the form, the left block shall contain, in

bold, "E. Check all that apply" and the right block shall be

headed, in bold, "Patient Preferences as a Basis for this POLST

Form" shall include the following:

a. below the heading there shall be a box including the

words, in bold, "Patient Goals/Medical Condition:"

followed by an adequate space for such information,

b. below this there shall be a checkbox followed by, "The

patient has an advance directive for health care in

accordance with Sections 3101.4 or 3101.14 of Title 63

of the Oklahoma Statutes." Below that there shall be

a checkbox followed by, "The patient has a durable

power of attorney for health care decisions in

accordance with the Oklahoma Health Care Agent Act."

Below that shall be the indented words, "Date of

execution" followed by an underlined space. Below

that shall be the words, "If POLST not being executed

by patient: We certify that this POLST is in

accordance with the patient's advance directive."

Below this there shall be an underlined space
power of attorney for health care decisions in

accordance with the Oklahoma Health Care Agent Act."

Below that shall be the indented words, "Date of

execution" followed by an underlined space. Below

that shall be the words, "If POLST not being executed

by patient: We certify that this POLST is in

accordance with the patient's advance directive."

Below this there shall be an underlined space

underneath which shall be positioned the words, "Name

and Position (print) Signature" and "Signature of

Physician",

c. below these shall be the words, "Directions given by:"

and below that a checkbox followed by "Patient", a

checkbox followed by "Minor's custodial parent or

guardian", a checkbox followed by "Attorney-in-fact",

a checkbox followed by "Health care proxy", and a

checkbox followed by "Other legally authorized

person:" followed by an underlined space. Beneath or

beside the checkbox and "Other legally authorized

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person:" and the underlined space shall be the words

"Basis of Authority:" followed by an underlined space,

and

d. below these shall be a four-column table with four

rows. In the top row the first column shall be blank;

the second column shall have the words, "Printed

Name"; the third column shall have the word,

"Signature", and the fourth column shall have the

word, "Date". In the remaining rows the second

through fourth columns shall be blank. In the first

column of these rows, in the second row shall be the

words, "Attending physician"; in the third row shall

be the words, "Patient or other individual checked

above (patient's representative)"; and in the fourth

row shall be the words, "Health care professional

preparing form (besides doctor)."

8. Section F of the form, which shall have the heading, in

bold, "Information for Patient or Representative of Patient Named on

this Form", shall include the following language, appearing in bold

on the form:

"The POLST form is always voluntary and is usually for persons

with advanced illness. Before providing information for or signing

it, carefully read "Information for Patients and Their Families -

Your Medical Treatment Rights Under Oklahoma Law", which the health

care provider must give you. It is especially important to read the

sections on CPR and food and fluids, which have summaries of

Oklahoma laws that may control the directions you may give. POLST

records your wishes for medical treatment in your current state of

health. Once initial medical treatment is begun and the risks and

benefits of further therapy are clear, your treatment wishes may

change. Your medical care and this form can be changed to reflect

your new wishes at any time. However, no form can address all the

medical treatment decisions that may need to be made. An advance

health care directive is recommended, regardless of your health

status. An advance directive allows you to document in detail your

future health care instructions and/or name a health care agent to

speak for you if you are unable to speak for yourself.

The State of Oklahoma affirms that the lives of all are of equal

dignity regardless of age or disability and emphasizes that no one

should ever feel pressured to agree to forego life-preserving

medical treatment because of age, disability or fear of being

regarded as a burden.

If this form is for a minor for whom you are authorized to make

health care decisions, you may not direct denial of medical

treatment in a manner that would violate the child abuse and neglect

laws of Oklahoma. In particular, you may not direct the withholding

of medically indicated treatment from a disabled infant with life-

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threatening conditions, as those terms are defined in 42 U.S.C.,

Section 5106g or regulations implementing it and 42 U.S.C., Section

5106a."
manner that would violate the child abuse and neglect

laws of Oklahoma. In particular, you may not direct the withholding

of medically indicated treatment from a disabled infant with life-

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threatening conditions, as those terms are defined in 42 U.S.C.,

Section 5106g or regulations implementing it and 42 U.S.C., Section

5106a."

9. Section G of the form, which shall have the heading, in

bold, "Directions for Completing and Implementing Form", shall

include the following three subdivisions:

a. the first subdivision, entitled "COMPLETING POLST",

shall have the following language with the words, "The

signature of the patient or the patient's

representative is required" appearing in bold on the

form:

"POLST must be reviewed and prepared in consultation

with the patient or the patient's representative after

that person has been given a copy of "Information for

Patients and Their Families - Your Medical Treatment

Rights Under Oklahoma Law". POLST must be reviewed

and signed by a physician to be valid. Be sure to

document the basis for concluding the patient had or

lacked capacity at the time of execution of the form

in the patient's medical record. If the patient lacks

capacity, any current advance directive form must be

reviewed and the patient's representative and

physician must both certify that POLST complies with

it. The signature of the patient or the patient's

representative is required; however, if the patient's

representative is not reasonably available to sign the

original form, a copy of the completed form with the

signature of the patient's representative must be

placed in the medical record as soon as practicable

and "on file" must be written on the appropriate

signature line on this form.",

b. the second subdivision, entitled "IMPLEMENTING POLST",

shall have the following language:

"If a minor protests a directive to deny the minor

life-preserving medical treatment, the denial of

treatment may not be implemented pending issuance of a

judicial order resolving the conflict. A health care

provider unwilling to comply with POLST must comply

with the transfer and treatment pending transfer

requirements of Section 3101.9 of Title 63 of the

Oklahoma Statutes as well as those of the

Nondiscrimination in Treatment Act, Sections 3090.2

and 3090.3 of Title 63 of the Oklahoma Statutes", and

c. the third subdivision, entitled "REVIEWING POLST",

shall have the following language:

"This POLST must be reviewed at least annually or

earlier if:

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The patient is admitted to or discharged from a

medical care facility; there is substantial change in

the patient's health status; or the treatment

preferences of the patient or patient's representative

change."

The same requirements for participation of the patient or

patient's representative, and signature by both a physician and the

patient or the patient's representative, that are described under

"COMPLETING POLST" shall also apply when POLST is reviewed, and must

be documented in Section I.

10. Section H of the form, which shall have the heading, in

bold, "REVOCATION OF POLST", shall have the following language, with

the words specified below appearing in bold on the form:

"If POLST is revised or becomes invalid, write in bold the word

"VOID" in large letters on the front of the form. After voiding the

form a new form may be completed. A patient with capacity or the

individual or individuals authorized to sign on behalf of the

patient in Section E of this form may void this form. If no new

form is completed, full treatment and resuscitation is to be

provided, except as otherwise authorized by Oklahoma law."

11. Section I of the form, which shall have the heading, in