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Oklahoma ______________________________________________ -5- ______________________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ve was signed in my presence. _____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ ________ay of _____________, 20 _____. ________________________________________ (Signature) ___________________________________________________________ City, County and State of Residence 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 ___________ de 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 directifuse 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 btions 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 -4- final expression of my legal right to reas 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 direcicate otherwise. ______________________________________________________________________________ _______________________ (signature) V. General Provisions a. I understand that if I have been diagnosed eted both a living will and have appointed a health care proxy, and if there is a conflict between my health care proxy's decision and my living will, my living will shall take precedence unless I ind] tissue, [___] arteries, [___] eyes/cornea/lens, [___] glands, [___] other _____________ ______________ _______________________ (signature) IV. Conflicting Provision I understand that if I have comply entire body; or [___] The following body organs or parts: [___] lungs, [___] liver, [___] pancreas, [___] heart, [___] kidneys, [___] brain, [___] skin, [___] bones/marrow, [___] bloods/fluids, [___th 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: [___] M 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. Dea_________________________________________________________ _______________________ (signature) III. Anatomical Gifts -3- I direct that at the time of my death my entire body or designated body organsd other medical directives, if any) _________________________________________________________________________ _________________________________________________________________________ ________________n this paragraph, I am authorizing the withholding and withdrawal of artificially administered nutrition and hydration. _______________________ (signature) (3) I authorize my health care proxy to (adarticular 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 sigawareness 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 pg 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 ____________________________________________________________ _______________________ (signature) c. If I am persistently unconscious: (1) I authorize my health care proxy to direct that life-sustainin_____________________ (signature) (3) I authorize my health care proxy to (add other medical directives, if any) _________________________________________________________________________ _____________ydration (water) 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 and hydration. __he 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 hble condition that even with the administration of life-sustaining treatment will cause my death within six (6) months. _______________________ (signature) -2- (2) I understand that the subject of ttaining 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 irreversiade by my health care proxy or alternate health care proxy only as I indicate in the following sections. b. If I have a terminal condition: (1) I authorize my health care proxy to direct that life-sus 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 lifesustaining treatment can be m______, 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 proxyysician and other health care providers pursuant to the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act to follow the instructions of ____________________________________________ My Appointment of My Health Care Proxy a. 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 ph____________ _________________________________________________________________________ _________________________________________________________________________ _______________________ (signature) II.tered nutrition (food) and hydration (water). _______________________ (signature) (3) I direct that (add other medical directives, if any) _____________________________________________________________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 adminisial 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, 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 artific I am persistently unconscious: -1- (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 es, if any) _________________________________________________________________________ _________________________________________________________________________ ______________________.(signature) c. Ifh, I am authorizing the withholding or withdrawal of artificially administered nutrition (food) and hydration (water). _______________________ (signature) (3) I direct that (add other medical directivarticular 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 paragrapnderstand 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 phat 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 uon: (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 tme under the circumstances I have indicated below by my signature. I understand that I will be given treatment that is necessary for my comfort or to alleviate my pain. b. If I have a terminal conditieatment, I direct my attending physician and other health care providers, pursuant to the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act, to withhold or withdraw treatment from circumstances set forth below. I thus do hereby declare: I. Living Will a. If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical tr 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 theund at findlegalforms.com -4- Advance Directive for Health Care I, _______________________________________________________, being of sound mind and eighteen (18) years of age or older, willfully andparty. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use fousing or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another al and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for leg Such designation shall be specified and included as part of the advanced directive executed pursuant to the provisions of this section. [_] These forms are provided "as is" and no implied or express fs 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. in the patient's advance directive. E. A person executing an advanced directive appointing a health care proxy who may not have an attending physician for reasons based on established religious beliein consultation with the attending physician, shall have the authority to make treatment decisions for the patient including the withholding or withdrawal of life-sustaining procedures if so indicatedart of the Declarant's medical record and, if unwilling to comply with the advance directive, promptly so advise the Declarant. D. In the case of a qualified patient, the patient's health care proxy, shall be in substantially the following form: (Form included below) C. A physician or other health care provider who is furnished the original or a photocopy of the advance directive shall make it a padvance 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 ocedures. A. An individual of sound mind and eighteen (18) years of age or older may execute at any time an advance directive governing the withholding or withdrawal of life-sustaining treatment. The ess to the revocation. B. The attending physician or other health care provider shall make the revocation a part of the Declarant's medical record. -3- Section 3101.4 - Advance Directive Form and Prlarant, without regard to the Declarant's mental or physical condition. A revocation is effective upon communication to the attending physician or other health care provider by the Declarant or a witnperative pursuant to subsection A of this section. Section 3101.6 - Revocation of Advance Directive. A. An advance directive may be revoked in whole or in part at any time and in any manner by the Decn the event more than one valid advance directive has been executed and not revoked, the last advance directive so executed shall be construed to be the last wishes of the Declarant and shall become ohe advance directive becomes operative, the attending physician and other health care providers shall act in accordance with its provisions or comply with the provisions of Section 9 of this act. B. Iirective becomes operative when: 1. It is communicated to the attending physician; and 2. The Declarant is no longer able to make decisions regarding administration of lifesustaining treatment. When tning treatment, will, in the opinion of the attending physician and another physician, result in death within six (6) months. Section 3101.5 - When Advance Directive Becomes Operative. A. An advance dnited States, the District of Columbia, or the Commonwealth of Puerto Rico; and 12. "Terminal condition" means an incurable and irreversible condition that, even with the administration of life-sustaia terminal condition or in a persistently unconscious state by the attending physician and another physician who have examined the patient; 11. "State" means a state, territory, or possession of the Uual licensed to practice medicine in this state; 10. "Qualified patient" means a patient eighteen (18) years of age or older who has executed an advance directive and who has been determined to be in ration, business trust, estate, trust, partnership, association, joint venture, government, governmental subdivision or agency, or any other legal or commercial entity; 9. "Physician" means an individ irreversible condition, as determined by the attending physician and another physician, in which thought and awareness of self and environment are absent; -2- 8. "Person" means an individual, corpoude the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain nor the normal consumption of food and water; 7. "Persistently unconscious" means anred to a qualified patient, will serve only to prolong the process of dying or to maintain the patient in a condition of persistent unconsciousness. The term "life-sustaining treatment" shall not inclificial administration of nutrition and hydration if the Declarant has specifically authorized the withholding and withdrawal of artificially administered nutrition and hydration, that, when administeconscious, incompetent, or otherwise mentally or physically incapable of communication; 6. "Life-sustaining treatment" means any medical procedure or intervention, including but not limited to the artions including but not limited to the withholding or withdrawal of life-sustaining treatment if a qualified patient, in the opinion of the attending physician and another physician, is persistently undinary course of business or practice of a profession; 5. "Health care proxy" is an individual eighteen (18) years old or older appointed by the Declarant as attorney-in-fact to make health care decisocedure provided for in Section 4 of this act; 4. "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the oring physician" means the physician who has primary responsibility for the treatment and care of the patient; 3. "Declarant" means any individual who has issued an advance directive according to the pruted in accordance with the requirements of Section 4 of this act and may include a living will, the appointment of a health care proxy, or both such living will and appointment of a proxy; 2. "Attendcide, or euthanasia. Section 3101.3 - Terms Defined. As used in the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act: 1. "Advance directive for health care" means any writing exeche individual and the decisions of an authorized proxy. C. The Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act does not condone, authorize, or approve mercy killing, assisted suima Rights of the Terminally Ill or Persistently Unconscious Act also includes necessary and appropriate protection for proxies and health care providers who rely in good faith on the instructions of tcapacity and the delegation of decision-making powers to a health care proxy. -1- B. To be sure that the individual's health care instructions and proxy decision-making will be effective, the Oklahoal's advance directive for health care will continue to be honored during incapacity without court involvement; and 5. Encourage and support health care instructions by the individual in advance of in and to act as the proxy decision-maker of last resort when no other proxy is authorized by the individual or is otherwise authorized by law; 4. Restate and clarify the law to ensure that the individus should be based on the proxy's reasonable judgment about the individual's values and what the individual's wishes would be based upon those values. The proper role of the court is to settle disputesest interests of the individual. If evidence of the individual's wishes is sufficient, those wishes should control; if there is not sufficient evidence of the individual's wishes, the proxy's decisiononal issues that do not belong in court, even if the individual is incapacitated, so long as a proxy decision-maker can make the necessary decisions based on the known intentions, personal views, or btion the physician and other health care providers may have to render care or to preserve life and health; 3. Recognize that decisions concerning one's medical treatment involve highly sensitive, pers, even if death ensues; 2. Recognize that the right of individuals to control some aspects of their own medical treatment is protected by the Constitution of the United States and overrides any obligaecognize the right of individuals to control some aspects of their own medical care and treatment, including but not limited to the right to decline medical treatment or to direct that it be withdrawntutes relating to the Oklahoma Power of Attorney for Health Care Form. Section 3101.2 - Purpose. A. The purpose of the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act is to: 1. Realth Care (Power of Attorney for Health Care & Living Will) is based Title 63; Chapter 60; Section 3101.2 et. Seq. of the on Oklahoma Statutes. The following are useful excerpts from the Oklahoma Stalth Care (Power of Attorney for Health Care & Living Will); (2) Oklahoma Advance Directive for Health Care (Power of Attorney for Health Care & Living Will) Form. This Oklahoma Advance Directive for HInformation and Instructions Oklahoma Advance Directive for Health Care (Power of Attorney for Health Care) This package contains (1) Information and Instruction for Oklahoma Advance Directive for Hea Oklahoma