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STATE OF OKLAHOMA
ADVANCE DIRECTIVE FOR HEALTH CARE
I, __________________, being of
sound mind and eighteen (18) years of age or older, willfully
and voluntarily make known my desire, by my instructions to others
through my living will, or by my appointment of a health care
proxy, or both, that my life shall not be artificially prolonged
under the circumstances set forth below. I thus do hereby declare:
I. LIVING WILL
b. If I have a terminal
condition:
(1) I direct that
life-sustaining treatment shall be withheld or withdrawn if such
treatment would only prolong my process of dying, and if my attending
physician and another physician determine that I have an
incurable and irreversible condition that even with the
administration of life-sustaining treatment will cause my death within six
(6) months.
Signature:
______________________________
(2) I understand that the
subject of the artificial administration of nutrition and hydration
(food and water) that will only prolong the process of dying from an
incurable and irreversible condition is of particular
importance. I understand that if I do not sign this paragraph,
artificially administered nutrition and hydration will be administered
to me. I further understand that if I sign this paragraph, I am
authorizing the withholding or withdrawal of artificially
administered nutrition (food) and hydration (water).
Signature:
______________________________
(3) I direct that (add
other medical directives, if any):___________________
____________________________________________________________________________
____________________________________________________________________________.
Signature:
______________________________
c. If I am
persistently unconscious:
(1) I direct that
life-sustaining treatment be withheld or withdrawn if such treatment
will only serve to maintain me in an irreversible condition, as
determined by my attending physician and another physician, in
which thought and awareness of self and environment are absent.
Signature:
______________________________
(2) I understand that the
subject of the artificial administration of nutrition and hydration (food
and water) for individuals who have become persistently unconscious is
of particular importance. I understand that if I do not sign this
paragraph, artificially administered nutrition and hydration will be
administered to me. I further understand that if I sign this paragraph,
I am authorizing the withholding or withdrawal of artificially
administered nutrition (food) and hydration (water).
Signature:
______________________________
(3) I direct that (add
other medical directives, if any): _____________________
_______________________________________________________________________________
Signature:
______________________________
II. MY APPOINTMENT OF MY HEALTH CARE PROXY
b. If I have a terminal
condition:
(1) I authorize my health
care proxy to direct that life-sustaining treatment be withheld or
withdrawn if such treatment would only prolong my process of dying and
if my attending physician and another physician determine that I have
an incurable and irreversible condition that even with the
administration of life-sustaining treatment will cause my death
within six (6) months.
Signature:
______________________________
(2) I understand that the
subject of the artificial administration of nutrition and hydration (food
and water) is of particular importance. I understand that if I do not
sign this paragraph, artificially administered nutrition (food)
or hydration (water) will be administered to me. I further
understand that if I sign this paragraph, I am authorizing the
withholding and withdrawal of artificially administered nutrition and
hydration.
Signature:
______________________________
(3) I authorize my health
care proxy to (add other medical directives, if any)
_______________________________________________________________________________
_______________________________________________________________________________
Signature:
______________________________
c. If I am persistently
unconscious:
(1) I authorize my health
care proxy to direct that life-sustaining treatment be withheld or
withdrawn if such treatment will only serve to maintain me in an
irreversible condition, as determined by my attending physician
and another physician, in which thought and awareness of self
and environment are absent.
Signature:
______________________________
(2) I understand that the
subject of the artificial administration of nutrition and hydration
(food and water) is of particular importance. I understand that if I
do not sign this paragraph, artificially administered nutrition
(food) and hydration (water) will be administered to me. I
further understand that if I sign this paragraph, I am authorizing
the withholding and withdrawal of artificially administered nutrition
and hydration.
Signature:
______________________________
(3) I authorize my health
care proxy to (add other medical directives, if any)
_______________________________________________________________________________
_______________________________________________________________________________
Signature:
______________________________
III. ANATOMICAL GIFTS
I direct that at the time of my death my entire body or designated body organs or body parts be donated for purposes of transplantation, therapy, advancement of medical or dental science or research or education pursuant to the provisions of the Uniform Anatomical Gift Act. Death means either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem. I specifically donate:
o My entire body; or o the following body organs or parts:
o lungs, o liver, o pancreas, o kidneys, o brain, o skin, o bones/marrow, o blood/fluids,
o tissue,
o
arteries,
o
eyes/cornea/lens,
o
glands, o
other
_______________________________________________________________________________
_______________________________________________________________________________
Signature:
______________________________
IV. CONFLICTING PROVISION
Signature:
______________________________
V. GENERAL PROVISIONS
a. I understand that if I
have been diagnosed as pregnant and that diagnosis is known to my
attending physician, this Advance Directive shall have no force or
effect during the course of my pregnancy.
b. 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 refuse medical or surgical treatment including,
but not limited to, the administration of any life-sustaining
procedures, and I accept the consequences of such refusal.
c. This Advance Directive
shall be in effect until it is revoked.
d. I understand that I may
revoke this Advance Directive at any time.
e. I understand and agree
that if I have any prior directives, and if I sign this Advance
Directive, my prior directives are revoked.
f. I understand the
full importance of this Advance Directive, and I am emotionally and
mentally competent to make this Advance Directive.
Signed this
____________day of __________________, 20_______.
Signature________________________________
City__________________County__________________State
of Residence_________________
Date of
Birth_________________Social Security Number___________________
This Advance Directive was
signed in my presence.
__________________________
_______________________________
Signature of
Witness
Address
__________________________
_______________________________
Signature of
Witness
Address
This Advance Directive for Health Care is copied from House Bill 1969 amending the 1992 form.
This law is effective November 1,1995. The 1992 forms properly executed prior to November 1, 1995
remain valid and enforceable.
This Advance Directive is provided by
the Oklahoma
Alliance for Better Care of the Dying.
For an Advance Directive in Spanish or Vietnamese, go to www.okdhs.org/aging
For an Advance Directive from another state, go to: http://www.uslivingwillregistry.com/forms.shtm
This Advance Directive is printable.
For bulk copies, you may call