Advance Directive For Health Care

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STATE OF OKLAHOMA
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 initials. 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 or am persistently unconscious:
(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I direct that life-sustaining treatment shall be withheld or withdrawn if such treatment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:
(a)
have an incurable and irreversible condition that even with the administration
of life-sustaining treatment will cause my death within six (6) months, or
Initial one box only
Q
Q
YES
NO
(b)
am in an irreversible condition in which thought and awareness of self and
environment are absent.
Initial one box only
Q
Q
YES
NO
(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 or for individuals who have become persistently unconscious
is of particular importance. I understand that if I do not initial the “yes” boxes below,
artificially administered nutrition and hydration will be administered to me. I further
understand that if I initial the “yes” boxes below, I am authorizing the withholding or
withdrawal of artificially administered nutrition (food) and hydration (water):

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