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63-3131.5.


63-3131.5.
   
   A. For persons under the care of a health care agency, a
   do-not-resuscitate order shall, if issued, be in accordance with the
   policies and procedures of the health care agency as long as not in
   conflict with the provisions of the Oklahoma Do-Not-Resuscitate Act.
   
   B. The do-not-resuscitate consent form shall be in substantially the
   following form:
   
                                 FRONT PAGE
                                      
               OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM
                                      
   I, _________________________, request limited health care as described
   in this document. If my heart stops beating or if I stop breathing, no
   medical procedure to restore breathing or heart function will be
   instituted by any health care provider including, but not limited to,
   emergency medical services (EMS) personnel.
   
   I understand that this decision will not prevent me from receiving
   other health care such as the Heimlich maneuver or oxygen and other
   comfort care measures.
   
   I understand that I may revoke this consent at any time in one of the
   following ways:
   
   1. If I am under the care of a health care agency, by making an oral,
   written, or other act of communication to a physician or other health
   care provider of a health care agency;
   
   2. If I am not under the care of a health care agency, by destroying
   my do-not-resuscitate form, removing all do-not-resuscitate
   identification from my person, and notifying my attending physician of
   the revocation;
   
   3. If I am incapacitated and under the care of a health care agency,
   my representative may revoke the do-not-resuscitate consent by written
   notification of a physician or other health care provider of the
   health care agency or by oral notification of my attending physician;
   or
   
   4. If I am incapacitated and not under the care of a health care
   agency, my representative may revoke the do-not-resuscitate consent by
   destroying the do-not-resuscitate form, removing all
   do-not-resuscitate identification from my person, and notifying my
   attending physician of the revocation.
   
   I give permission for this information to be given to EMS personnel,
   doctors, nurses, and other health care providers. I hereby state that
   I am making an informed decision and agree to a do-not-resuscitate
   order.
   
   ____________________ OR ________________________________
   
   Signature of Person Signature of Representative
   
   (Limited to an attorney-in-fact for health care decisions acting under
   the Durable Power of Attorney Act, a health care proxy acting under
   the Oklahoma Rights of the Terminally Ill or Persistently Unconscious
   Act or a guardian of the person appointed under the Oklahoma
   Guardianship and Conservatorship Act.)
   
   This DNR consent form was signed in my presence.
   
   ______________ ______________________ _____________
   
   Date Signature of Witness Address
   
   ______________________ _____________
   
   Signature of Witness Address
   
                                BACK OF PAGE
                                      
                         CERTIFICATION OF PHYSICIAN
                                      
   (This form is to be used by an attending physician only to certify
   that an incapacitated person without a representative would not have
   consented to the administration of cardiopulmonary resuscitation in
   the event of cardiac or respiratory arrest. An attending physician of
   an incapacitated person without a representative must know by clear
   and convincing evidence that the incapacitated person, when competent,
   decided on the basis of information sufficient to constitute informed
   consent that such person would not have consented to the
   administration of cardiopulmonary resuscitation in the event of
   cardiac or respiratory arrest. Clear and convincing evidence for this
   purpose shall include oral, written, or other acts of communication
   between the patient, when competent, and family members, health care
   providers, or others close to the patient with knowledge of the
   patient's desires.)
   
   I hereby certify, based on clear and convincing evidence presented to
   me, that I believe that ___________________________
   
   Name of Incapacitated Person
   
   would not have consented to the administration of cardiopulmonary
   resuscitation in the event of cardiac or respiratory arrest.
   Therefore, in the event of cardiac or respiratory arrest, no chest
   compressions, artificial ventilation, intubations, defibrillation, or
   emergency cardiac medications are to be initiated.
   
   __________________________ _____________________________
   
   Physician's Signature/Date Physician's Name (PRINT)
   
   _________________________________________________________________
   
   Physician's Address/Phone
   
   C. Witnesses must be individuals who are eighteen (18) years of age or
   older who are not legatees, devisees or heirs at law.
   
   D. It is the intention of the Legislature that the preferred, but not
   required, do-not-resuscitate form in Oklahoma shall be the form set
   out in subsection B of this section.
   

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