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63-3101.4.


63-3101.4.
   
   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 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 shall be in substantially the following form:
   
                     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
                                      
   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 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 me 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 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   withdrawn if such treatment would only prolong my process of dying,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
                                      
   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 physician and other health care providers pursuant
   to the Oklahoma Rights of the Terminally Ill or Persistently
   Unconscious 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 can be
   made 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-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 or 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:
   
   [ ] My entire body; or
   
   [ ] The following body organs or parts:
   
   ( ) lungs, ( ) liver, ( ) pancreas,
   
   ( ) heart, ( ) kidneys, ( ) brain,
   
   ( ) skin, ( ) bones/marrow,
   
   ( ) bloods/fluids, ( ) tissue,
   
   ( ) arteries, ( ) eyes/cornea/lens,
   
   ( ) glands, ( ) other _____________
   
   ______________. ________ (signature)
   
                         IV. Conflicting Provision
                                      
   I understand that if I have completed 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 indicate otherwise.
   
   ____________________. ___________ (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 __________, 19 __.
   
   ___________________________________
   
   (Signature)
   
   ___________________________________
   
   City, County and State of Residence
   
             This advance directive was signed in my presence.
                                      
   ___________________________________
   
   (Signature of Witness)
   
   ___________________________________
   
   (Address)
   
   ___________________________________
   
   (Signature of Witness)
   
   ___________________________________
   
   (Address)
   
   C. 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.
   
   D. 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
   withholding or withdrawal of life-sustaining procedures if so
   indicated 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 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 advanced directive executed pursuant to the
   provisions of this section.
   

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