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
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
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
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;
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
____________________ 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
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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
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)
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.