Oklahoma Advance Directive

Oklahoma Advance Directive for Health Care

If I am incapable of making an informed decision regarding my health care, I direct my health care
providers to follow my instructions below.

I. Living Will

(1) If I have a terminal condition, that is, an incurable and irreversible condition that even with the
administration of life-sustaining treatment will, in the opinion of the attending physician and another
physician, result in death within six (6) months:

(Initial only one option)
_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take
food and water by mouth, I wish to receive artificially administered nutrition and hydration.
_____ I direct that my life not be extended by life-sustaining treatment, including artificially
administered nutrition and hydration.
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by
mouth, I wish to receive artificially administered nutrition and hydration.

(Initial only if applicable)
_____ See my more specific instructions in paragraph (4) below.

(2) If I am persistently unconscious, that is, I have an irreversible condition, as determined by the
attending physician and another physician, in which thought and awareness of self and environment are
absent:
(Initial only one option)
_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take
food and water by mouth, I wish to receive artificially administered nutrition and hydration.
_____ I direct that my life not be extended by life-sustaining treatment, including artificially
administered nutrition and hydration.
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by
mouth, I wish to receive artificially administered nutrition and hydration.

(Initial only if applicable)
_____ See my more specific instructions in paragraph (4) below.

(3) If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, which
results in severe and permanent deterioration indicated by incompetency and complete physical
dependency for which treatment of the irreversible condition would be medically ineffective:
(Initial only one option)
_____ I direct that my life not be extended by life-sustaining treatment, except that if I am unable to take
food and water by mouth, I wish to receive artificially administered nutrition and hydration.
_____ I direct that my life not be extended by life-sustaining treatment, including artificially
administered nutrition and hydration.
_____ I direct that I be given life-sustaining treatment and, if I am unable to take food and water by
mouth, I wish to receive artificially administered nutrition and hydration.

(Initial only if applicable)
_____ See my more specific instructions in paragraph (4) below.

(4) OTHER. Here you may:

(a) describe other conditions in which you would want life-sustaining treatment or artificially
administered nutrition and hydration provided, withheld, or withdrawn,
(b) give more specific instructions about your wishes concerning life-sustaining treatment or artificially
administered nutrition and hydration if you have a terminal condition, are persistently unconscious, or
have an end-stage condition, or
(c) do both of these:

____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_______
Initial

II. My Appointment of My Health Care Proxy

If my attending physician and another physician determine that I am no longer able to make decisions
regarding my health care, I direct my attending physician and other health care providers pursuant to the
Oklahoma Advance Directive 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 healthcare proxy or alternate is authorized to make whatever healthcare decisions I could make if I were able regarding medical treatment, including life-sustaining treatment and artificially administered nutrition and hydration.

III. Anatomical Gifts

Pursuant to the provisions of the Uniform Anatomical Gift Act, I direct that at the time of my death my
entire body or designated body organs or body parts be donated for purposes of:
(Initial all that apply)
_____ transplantation
OR
_____ advancement of medical science, research, or education
_____ advancement of dental science, research, or education

Death means either irreversible cessation of circulatory and respiratory functions or irreversible
cessation of all functions of the entire brain, including the brain stem. If I initial the “yes” line below, I
specifically donate:

_____ My entire body
or
_____ The following body organs or parts:
_____ lungs
_____ pancreas
_____ kidneys
_____ skin
_____ blood/fluids
_____ arteries
_____ liver
_____ heart
_____ brain
_____ bones/marrow
_____ tissue
_____ eyes/cornea/lens

IV. General Provisions

a. I understand that I must be eighteen (18) years of age or older to execute this form.
b. I understand that my witnesses must be eighteen (18) years of age or older and shall not be related to me
and shall not inherit from me.
c. I understand that if I have been diagnosed as pregnant and that diagnosis is known to my attending
physician, I will be provided with life-sustaining treatment and artificially administered hydration and
nutrition unless I have, in my own words, specifically authorized that during a course of pregnancy, lifesustaining
treatment and/or artificially administered hydration and/or nutrition shall be withheld or
withdrawn.
d. 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 choose or refuse medical or surgical treatment including, but not limited to, the
administration of life-sustaining procedures, and I accept the consequences of such choice or refusal.
e. This advance directive shall be in effect until it is revoked.
f. I understand that I may revoke this advance directive at any time.
g. I understand and agree that if I have any prior directives, and if I sign this advance directive, my prior
directives are revoked.
h. I understand the full importance of this advance directive and I am emotionally and mentally competent to
make this advance directive.
i. I understand that my physician (s) shall make all decisions based upon his or her best judgment applying
with ordinary care and diligence the knowledge and skill that is possessed and used by members of the
physician’s profession in good standing engaged in the same field of practice at that time, measured by
national standards.

Signed this ___ day of ________________, 20 ___.

_____________________________________________
Signature
_____________________________________________
City of
_____________________________________________
County, Oklahoma
_____________________________________________
Date of birth (Optional for identification purposes)

This advance directive was signed in my presence.

_____________________________________________
Signature of Witness
____________________________________, OK
Residence

_____________________________________________
Signature of Witness
_________________________________, OK
Residence