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Oklahoma Advance Directive Form

An Oklahoma advance directive is a document used to outline a person's future health care plans and instructions for care. An advance directive allows someone to select an agent to handle their health care needs and to outline their medical treatment guidelines in case they cannot speak for themselves. Once signed, the form should be kept by the agent and close family members.

Four (4) Parts

Living Will;
My Appointment of My Health Care Proxy;
Anatomical Gifts; and
General Provisions.

Laws
- Signing Requirements
Versions (9)
- BAR Assoc.
- College of Medicine
- Dept. of Human Services
- Integris Health
- LegalAid Oklahoma
- McAlester Regional Health
- Oklahoma State Dept.
- St. John Health System
- Utica Park
How to Write
Related Forms
- Durable Power of Attorney
- Last Will and Testament

Laws

Statute – § 63-3101.4

Signing Requirements (§ 63-3101.4) – Two (2) witnesses.

State Definition (§ 63-3101.3(1)) – 1. "Advance directive for health care" means any writing executed in accordance with the requirements of Section 3101.4 of this title and may include a living will, the appointment of a health care proxy, or both such living will and appointment of a proxy;

Versions (9)

BAR Assoc.
College of Medicine
Dept. of Human Services
Integris Health
LegalAid Oklahoma
McAlester Regional Health
Oklahoma State Dept.
St. John Health System
Utica Park

BAR Assoc.

Download: Adobe PDF

College of Medicine

Download: Adobe PDF

Dept. of Human Services

Download: Adobe PDF

Integris Health

Download: Adobe PDF

LegalAid Oklahoma

Download: Adobe PDF

McAlester Regional Health

Download: Adobe PDF

Oklahoma State Dept.

Download: Adobe PDF, MS Word

St. John Health System

Download: Adobe PDF

Utica Park

Download: Adobe PDF

How to Write

Download: Adobe PDF, MS Word, OpenDocument

Article I Living Will

Directive 1 When An End-Of-Life Event Occurs

(1) Artificial Nutrition Approval. Select the first statement if you have decided that you do not wish to receive life-extending procedures but do not approve of having nutrition or water delivered medically (by tube or I.V.) when you have only six months before death after being diagnosed with an incurable medical condition.

(2) Withdrawal Of All Artificial Nutrition. If you prefer to deny both life-support or life-sustaining procedures as well as artificially delivered nutrition and water when you have six months to live, then select the second statement by producing your initials of approval.

(3) Request For Treatment. You can inform Oklahoma Physicians of your authorization to be administered life-support or life-sustaining treatment when you have been diagnosed with a terminal condition that will result in your death within six months by initialing this declaration.

(4) Specific Instructions. You can apply specific instructions to your treatment decision when you have a fatal medical condition that will cause death within six months. For instance, you may wish to receive artificial nutrition/water under certain circumstances, for a limited amount of time, or simply as a trial period.

Directive 2 When Persistently Unconscious

(5) Authorization For Artificial Nutrition. If you are rendered permanently unconscious in the State of Oklahoma, then Medical Providers will as a general rule try to prolong your life in the absence of any instructions from you. Additionally, they will seek to prevent a life-threatening level of malnutrition or dehydration especially since you will not be able to eat or drink while unconscious. Select the first option in this directive to establish that while you wish life-sustaining treatment withheld, you will not authorize the delivery of nutrition and water artificially. For example, by initialing this statement, Oklahoma Doctors will not be able to connect a tube to your stomach or administer an I.V. of fluids to keep nourished and hydrated.

(6) Denial Of Artificial Nutrition. If you wish to receive life-extending procedures and treatment when you are unconscious and do not wish to have a medical delivery of food or water to your system, then you must initial the second statement of Directive 2.

(7) Request Full Treatment Including Artificial Nutrition. If you have determined that Oklahoma Medical Providers should administer both life-sustaining treatments and keep you well-nourished and hydrated even if an artificial delivery of nutrients and liquids is necessary, then initial the third statement displayed.

(8) Additional Directive. In order for your directives to be set through this paperwork, all of them must be presented at the time of signing. This pertains to any directions over treatment that you want Oklahoma Health Care Professionals to provide once you are formally diagnosed as permanently unconscious.

Directive 3 When In An End-Stage Condition

(9) Requesting Artificial Nutrition Without Extending Life Treatment. If you have been pronounced, by Oklahoma Physicians, as being near death or the end-stage condition of a fatal medical condition then your body will fail in certain functions, including eating, drinking, and (often) remaining cognizant or communicative. Physicians in Oklahoma will refer to this section for your directives when this happens. To inform Oklahoma Medical Personnel that you do not wish to receive life-extending or life-sustaining treatment but still wish your nutrition and hydration levels maintained to as healthy a level as possible even when a tube insertion or an I.V. feed is necessary then, initial the first statement of Directive 2.

(10) Deny Both Life-Extending Treatment And Artificial Nutrition. This section enables you to inform Oklahoma Doctors that you do not wish life-sustaining procedures applied and that you refuse to receive nutrition and liquids through a tube or an I.V. This declaration will be made if you select the second statement in this area.

(11) Authorization For Life-Extending Treatment With Artificial Nutrition. If you are diagnosed as near-death and wish to receive the full scope of treatment that Oklahoma Medical Personnel can provide including using medical technology to insert nutrients and liquids into your system, then authorize the third statement with your initials.

(12) Directive 4 Other Information And Instructions. An end-stage medical condition of a fatal or terminal condition will mean that death may be very close. If you wish to include additional directives to Oklahoma Medical Professionals and other Reviewers of this document, then indicate an attachment with this information has been attached and should be sought out for more information.

Directive 4 Other Directives Or Preferences

(13) Directive Details. It is usually considered wise to include background information on any current medical conditions that you have which may affect treatment administered in the State of Ohio, any additional specific directions you wish documented on what treatments you find preferable and which you find intolerable, and quality of life concerns. All such information should be presented in this document using the space in Directive 4.

(14) Acknowledgment. Notice, that your initials will be required to approve of any statements made here. It is strongly recommended that if you intend to appoint a Health Care Surrogate and Alternate Surrogate, that you also list each one's contact information in this area as well.

Article II My Appointment Of My Health Care Proxy

(15) Oklahoma Health Care Proxy. A useful precaution to take would be to appoint an Oklahoma Health Care Surrogate. This Party will act to represent treatment decisions not addressed in the living will completed above. To make this appointment, provide the full name of the Person you authorize to act as your Health Care Surrogate. This Party will be sought out by Oklahoma Physicians seeking treatment decisions beyond the scope of your living will.

(16) Oklahoma Alternate Health Care Proxy. If Oklahoma Physicians seek out your Health Care Surrogate but are unable to make contact or are refused, then an Alternate Health Care Surrogate will be especially useful at a time when a decision on your treatment must be made. This Alternate Surrogate only receives the authority to represent your wishes if your original Surrogate declines or is unreachable and you list his or her name as being authorized to assume the Oklahoma Health Care Proxy or Surrogate position.

Article III Anatomical Gifts

(17) Purpose Of Anatomical Gifts. The State of Oklahoma allows you to declare your status as an Organ Donor in this state. If you wish to be an Oklahoma Organ Donor, then initial the reasons you approve an anatomical donation to be made. For instance, you may approve of making an anatomical gift in the State of Oklahoma for the purpose of transplantation, therapy, and/or advancements in medical or dental science, research, and education.

(18) Type Of Anatomical Gifts. Now the anatomical donations you wish to make should be discussed. To donate your whole body, write in a "Yes" next to "My Entire Body," otherwise you may review the list of acceptable anatomical gifts and approve only the ones you wish to make by writing in the word "Yes" next to each authorized donation.

Article IV General Provisions

(19) Authorized Anatomical Donations. If you prefer to make specific anatomical gifts, then review the list provided. Produce the word "Yes" next to each organ, tissue, or body part that you wish to donate once you have confirmed that you wish to donate only "the following body parts" that you list for approval.

(20) Signature Date. Review this entire document and every attachment coupled with it. If these items accurately show your health care preferences in the State of Oklahoma, then proceed to engage the execution of your directives with the date you are signing it.

(21) Oklahoma Principal Signature. Sign your name to this directive with any relevant documents physically attached while two Witnesses (both adult) watch.

(22) City And County. Record the city and the county where you live.

(23) Date Of Birth.

(23) Witness Signatures And Residential Information. Both Oklahoma Witnesses must sign their names and present their residential addresses below the affirmation statement testifying your signature was legally and willfully made to this document under their observance.