Advance Directive Patient Booklet

Steps to Create Your Advance Care Plan

Step 1: Evaluating Your Wishes, Beliefs, and Values

Step 2: Choosing Your Health Care Proxy (Decision-Maker)

Step 3: Having the Conversation

Step 4: Fill out an Advance Directive for Health Care

Step 5: Share Your Advance Directive

Step 6: Review Your Advance Directive

Oklahoma Advance Directive for Health Care Form

What is Advance Care Planning and Why Is It Important?

Advance Care Planning is the process of making decisions in advance of an illness or injury to express your choices if you became unable to communicate those choices yourself. Many people do not think about planning for their end-of-life care until they are older or very sick. However, anyone over the age of 18 should make a plan in case of a serious disease, accident, or sudden emergency such as surgery while able to do so. Oklahoma law assumes that persons want all possible treatment to keep them alive unless a completed Advance Directive Form states otherwise.

Why Do I Need Advance Care Planning?

Not only will planning for your care give you peace of mind, it will lessen the suffering of your loved ones. Without a written plan, you would receive all necessary medical treatment in the event you suddenly became sick or injured. If you were unable to speak for yourself, doctors would not know your wishes and your loved ones might be scared, overwhelmed, or unsure of what to do. You might already have strong beliefs about:

• Who you would like to make health care decisions for you.

• What treatments you would agree to or refuse in order to keep you alive.

• Where you choose to spend the last days of your life.

• Financial costs for treatments that may keep you alive but not make you better.

What is an Advance Directive?

An Advance Directive form is a legal document that allows you to write down your wishes for health care treatment during the end-stage of your life. This form will also allow you to appoint someone to be your voice (Health Care Proxy) if you are unable to speak for yourself. It is important to know that this form only becomes valid if two doctors have determined that you are unable to make medical decisions.

An Advance Directive Allows You To:

• Choose a person to make health care choices for you. You can also choose an alternate (back-up) person in the event your first choice is unable to speak for you.

• Indicate what health care treatments you would agree to or refuse.

• Choose if you would like to accept or refuse life support for certain conditions.

• Indicate if you would like to donate your body or organs for medical research or people waiting on transplant.

Terms to Know

There have been advancements in health care over the year, and it is more important than ever to understand your medical treatment and life-support options. We have included a list of definitions of things you might hear while discussing your end-of-life choices.

Advance Care Planning: The process of making decisions in advance of an illness or injury to express your choices if you became unable to communicate those choices yourself.

Advance Directive: A legal document that lets others know your medical care preferences and who you would like to make decisions for you if you are unable to speak for yourself.

Antibiotics: Medicine used to treat infections caused by bacteria.

Artificially Administered Nutrition and Hydration (Tube Feedings): A way to deliver nutrients and liquids to patients who are unable to eat or drink by mouth. Nutrition is provided by an IV (into a vein) or a tube inserted into your nose, stomach, or intestine (gut).

Artificial Life-Support Choices: Artificial life-support includes machines that are used to assist the body in keeping a patient alive. This can include several systems and we will discuss several in more detail later in this guide.

Comfort Care: Medical care provided with the primary goal of keeping a patient comfortable rather than prolonging life.

Cardiopulmonary Resuscitation (CPR): CPR is used to restart the heart and breathing of a patient. It involves chest compressions (pressing on the chest over the heart), rescue breathing (mouth-to-mouth or with a bag), and if needed, an automated external defibrillator (AED) that can deliver an electric shock to the heart. You have the right to choose your code status, meaning you can indicate if you would like CPR. Ask your doctor for more information if you have questions.

Code Status: This tells health care workers what treatment you would like if your heart stops beating or if you stop breathing.

1. Full Code: You want to receive cardiopulmonary resuscitation (CPR) to attempt to restart your heart or breathing.

2. Do Not Resuscitate (DNR): You wish to receive all appropriate medical treatment but if you stop breathing or your heart stops beating, you would like a natural death.

3. Do not Intubate/Do Not Resuscitate: You do not wish to have a breathing machine breathe for you at any point and you would like a natural death if you stop breathing or your heart stops beating.

4. Comfort Care: You wish to only receive care that provides comfort and allows for a natural death.

Do Not Resuscitate Order (DNR): Indicates the wish to not have CPR in the event the patient stops breathing and the heart stops beating

End-State Condition: Medical problem in an advanced state that will eventually cause death and cannot be cured. This can be caused by a disease or an injury.

Health Care Proxy: Adult that you select to make medical or end-of-life decisions for you if you are terminally ill, persistently unconscious, or in an end-stage condition. This applies only if you are unable to make your own decisions.

Hospice Care: Comfort care provided to patients who are expected to die within the next 6 months. The goals are to relieve symptoms as much as possible and provide a peaceful death. As many patients experience a decline in health, they begin to shift their priorities to spending meaningful time with loved ones. Hospice can provide similar care as palliative care and also includes:

• Therapies to conserve energy and provide peace.

• Respite care that provides a break to family or caregivers.

• Home health employees that will help with needs such as bathing or eating.

• Support such as grief counseling for family and caregivers.

Intubation: A procedure that is performed when you cannot breathe on your own or it is difficult to breathe on your own. A tube is placed down your throat and into your windpipe to open your airway so that air can get in and out of your lungs. Intubation is also used in many surgeries and with illnesses or injuries that weaken the airway.

Life-Sustaining Treatments: Medical treatment performed to keep a patient alive. Life-sustaining treatment can include:

• Antibiotic

• Ventilator/Respirator (breathing machine)

• Tube-feeding

• Intravenous (IV) fluids

• Chemotherapy

• Cardiopulmonary Resuscitation (CPR)

• Kidney dialysis

Pain medication and measures used to keep a dying patient comfortable are NOT considered life-sustaining treatments.

Living Will: Term used in the same way as Advance Directive or Advance Care Plan. This legal document provides your choices for health care in the event you are unable to communicate them yourself. This plan can express your values and beliefs in a health crisis.

Long-Term Care Facilities or Nursing Homes: These facilities can help patients who have severe injuries or illness and need assistance with personal care.

Long-Term Dialysis: Dialysis involves removing excess fluid and cleaning the blood of waste when the kidneys are not working properly. Dialysis can extend a patient’s life, especially while waiting on a kidney transplant. It is typical for a patient to need three dialysis treatments per week and each treatment can last anywhere from three to five hours. It is important to remember that dialysis does not cure kidney disease.

Mechanical Ventilator (Breathing Machine): This is a machine that breathes for a patient while trying to recover from an injury or illness. It is connected to a tube that pushes air and oxygen into your lungs if you cannot breathe on your own. A ventilator can save lives, but it is important to realize that it cannot cure a terminal illness or prevent the death of a patient who suffers a fatal accident. A patient that is on a ventilator is often sedated and cannot speak or cough. When a patient is unable to cough, the lungs can fill up with fluids, often causing pneumonia.

Palliative Care: Care available to patients who are living with a serious, long-term disease. Treatment for the disease can occur along with palliative care. It can be started at any stage of illness and focuses on:

• Symptom relief

• Coordinating care such as helping to make doctor appointments

• Helping with health care decisions

• Support for the patient and family

There are organizations that provide both palliative and hospice care. They can also help with the transition from palliative to hospice care if it is needed. Frequently, the patient has the right to choose that these services are provided at home. Ask your health care provider if you have questions about these services.

Persistently Unconscious State: The patient may have open eyes but the brain has little or no activity. Unlike patients in a coma, these patients will never “wake up” and do not feel pain, hunger, or thirst.

Terminal Condition: Caused by a disease or accident that cannot be cured or reversed. Two doctors must agree that even with treatment, death will likely occur within 6 months.

Step Evaluating1Your Wishes, Values, and Beliefs

Advance care planning involves making yourself aware of the medical terms and choices and then thinking about your wishes, values, and beliefs.

Each person holds their own beliefs and values when it comes to what is important in life. It is important to think about these values when choosing future medical needs.

Begin by asking yourself questions about your medical and personal values. Write down what would be important to you in the event you could not speak for yourself. We are including a few questions that you may ask yourself:

• Is it important for me to breathe on my own?

• Would I want tube feedings if I could not eat or drink by mouth?

• Is it important for me to be mentally alert and able to recognize loved ones?

• Would I want to live as long as possible regardless of the stage of my illness or injury?

• Would I like to help others by donating my organs?

• Would I want to live in a nursing home if I were unable to care for myself?

• Where would I like to spend the last days of my life?

• How would I like to include my religious beliefs and traditions in my end-of-life care?

• Would I like to have a natural death, not hooked up to machines or tubes?

Of course, there are many more questions that you might ask yourself when planning for your end-of-life care. Some situations may be difficult to think about. If you have questions or need support reach out to important people in you life such as loved ones, healthcare providers, or religious leaders.

Step 2

Choosing Your Health Care Proxy (Decision-Maker)

If you are not able, the person that you choose as your health care proxy (decision-maker) will have the authority to make all health care decisions that you would make if you were able. The form also contains a space that you can include an alternate (back-up) health care proxy in the event that your first choice is unable to speak for you.

Your health care proxy will have access to all of your medical records and will discuss your treatment with your doctors. He or she may allow or refuse any tests, procedures, or treatments that are discussed and admit you to another health care facility. Your proxy is required to follow your written wishes and must honor your instructions.

There are several things to take into consideration when choosing a health care proxy. Many people choose a spouse or adult child, but you can choose anyone who is at least 18 years old and of sound mind. This might include a family member, friend, neighbor, or member of your religious organization. When choosing your alternate proxy, you might choose someone younger if your primary person is your age or older.

When considering a health care proxy, you might choose someone who:

• Is willing to take responsibility to serve as your voice when needed.

• Is trustworthy.

• Is willing to talk to you about difficult situations.

• Will speak up on your behalf when you cannot speak.

• Understands your values.

• Is willing to follow your instructions and honor your wishes.

• Is able to make these difficult decisions in stressful situations.

• Can handle conflict if there is a disagreement about your health care.

Here are examples of what your health care proxy can do on your behalf:

• Talk with your healthcare team about your condition

• Give permission for medical tests, medications, surgery, or other treatments

• Choose where you get care

• Agree or decline to donate your organs or whole body for transplant, research, or education if you have not already made the decision yourself

• Decide what to do with your remains (your body) after you have died if you have not already made plans

• Talk with your loved ones to help come to a decision. Your healthcare proxy will have the final say.

• Your health care proxy is not responsible for your health care expenses.

Step 3 Having the Conversation

Now that you have chosen your health care proxy, it is important that you discuss your wishes. It may be difficult to start this conversation so plan ahead if possible. It might be a good idea to write down the things you would like to discuss. Choose a quiet place so that you might not be interrupted. You might also consider getting opinions from your loved ones about difficult medical decisions.

Start out by asking if he or she is comfortable taking on the role as your health care proxy. Point out the duties that would need to be carried out so that there is clear understanding of the role.

Next, share your wishes and the decisions that must be made. Share the things that you feel are important and matter to you when thinking about the last days of your life. Your health care proxy may have questions so listen carefully and try to answer to the best of your ability. Be patient and take your time. Both you and your loved one might need time to think. Do not forget to also have this conversation with your alternate proxy as well.

After sharing your wishes with your proxy, it would be a good idea to share your wishes with your family and loved ones. End-of-life situations are emotional and often stressful on family members and making your wishes known might help to alleviate conflict or disagreements.

Finally, share your wishes and your Advanced Health Care Directive form with your doctors. Your health care team will make a copy of your form to keep in your medical record. Also provide copies to your proxies and anyone that might need one.

Step

Fill out an Advance Directive for Health Care

How to Complete Your Advance Directive Form

Part I: Living Will

The first part of your Oklahoma Advance Directives for Health Care form contains a Living Will. This is the portion that you will make your choices for health care in the event you are unable to speak for yourself. This section is divided into three medical situations called 1) Terminal Condition, 2) Persistent Unconsciousness, and 3) End-Stage Condition. These conditions were listed in the glossary and here we will walk you through each step so that you can better understand your choices.

1. Terminal Condition is caused by a disease or injury. It is not curable and the condition will not improve. Two doctors must agree that the patient has a terminal condition, meaning that even if all medical treatment was performed, death will most likely occur within six months.

2. Persistent Unconsciousness means that the patient may have open eyes but has very little brain activity. Unlike patients that are in a coma, these patients will never “wake up” and do not feel pain, hunger, or thirst.

3. End-Stage Condition is a medical illness or injury that is in an advanced stage. The patient may experience loss of mental and physical abilities such as talking, walking, swallowing, or recognizing loved ones. A patient with an end-stage condition has a very low chance of recovering or improving with or without medical treatment.

With each of the conditions above, you can choose one of three actions and initial beside your choice. These choices are:

• Receive all life-sustaining treatment

• Receive no life-sustaining treatment EXCEPT artificial nutrition and hydration

• Receive no life-sustaining treatment

What is life-sustaining treatment?

This means that you wish to have any recommended medical treatment that would keep you alive. This might include a ventilator (breathing machine), feeding tubes, dialysis, chemotherapy, antibiotics, or surgery. You would initial by this choice if you wish for all of these treatments in any of the conditions above.

What is artificially administered nutrition and hydration?

This is also known as tube feedings. If you are still able to eat or drink by mouth safely, this does not apply. However, if a patient is unable to eat or drink anything by mouth, these feedings can be used to give nutrition and hydration for a short amount of time. These feedings are provided through an IV (into a vein) or a tube inserted into your nose, stomach, or intestine (gut). This will allow a patient to heal but can have some side effects such as discomfort, bloating, and risk of infection. It is possible that a tube can be dislodged so sometimes a patient will need to be physically restrained so that the tube will not be pulled out. If you have any questions or concerns about end-of-life tube feedings, speak with your doctor.

What if I choose to receive life-sustaining treatment including artificial nutrition and hydration?

If you make the choice to receive all life-sustaining treatment, this means that you wish to receive any of the medical treatments listed above to keep you alive. This includes tube feedings if you are unable to eat or drink by mouth. However, there are cases in which a doctor might not recommend a treatment because it will not help your condition or will cause you further harm.

What if I choose no life-sustaining treatment including artificial nutrition and hydration?

If you make this choice, this means that if doctors determine that you will not recover, you wish to refuse treatment so that you may have a natural death. However, even if you make this choice, you will be kept as comfortable as possible with treatment such as pain medication.

What if I choose NOT to have life-sustaining treatment but YES to artificial nutrition and hydration if needed?

If you make this choice, this means that you do not want any of the treatments defined above in order to keep you alive but you would like to have tube feedings if you are unable to eat or drink by mouth.

What about the part to initial for more specific instructions?

This is optional. There is a space to initial after each of the conditions if you would like to be more specific about your care. If you are unable to speak for yourself, you can write further instructions about your wishes in the space provided on the form. Notice that there is a place to initial after the optional instructions and it is required if you choose to write out instructions.

Now that we have discussed the Living Will portion of your Advance Directive for Health Care form, please look over the next few pages for an example. We have included arrows indicating where you would initial for each choice. Please remember that you should only initial by one choice in sections one, two, and three. Section four is optional and is where you would write out any further instructions.

Your Advance Directive will only be used if your attending physician and another physician determine that you are unable to make medical decisions.

(1) Choose whether you would want life-sustaining treatment and/or tube feeding if you have a terminal illness that even with treatment, will likely result in death within 6 months.

Initial here if you DO NOT want life-sustaining treatment, but you DO want tube feeding.

Initial here if you DO NOT want life-sustaining treatment and you DO NOT want tube feeding.

Initial here if you DO want BOTH life-sustaining treatment and tube

Initialfeeding.here

only if you have written instructions regarding treatment or tube feeding in the event of a terminal

(2)illness.Choose

whether you would want life-sustaining treatment and/or tube feeding if you become persistently

Initialunconscious.hereifyou

DO NOT want life-sustaining treatment, but you DO want tube feeding.

Initial here if you DO NOT want life-sustaining treatment and you DO NOT want tube feeding.

Initial here if you DO want BOTH life-sustaining treatment and tube

Initialfeeding.here

only if you have written instructions regarding treatment or tube feeding in the event you become persistently unconscious.

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

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 my instructions as set forth below:

(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) Choose whether you would want life-sustaining treatment and/or tube feeding if you have an incurable con dition causing you to be incompetent and completely dependent.

Initial here if you DO NOT want life-sustaining treatment, but you DO want tube feeding.

Initial here if you DO NOT want life-sustaining treatment and you DO NOT want tube feeding.

Initial here if you DO want BOTH life-sustaining treatment and tube Initialfeeding.here

only if you have written instructions regarding treatment or tube feeding in the event you have an end-state condition.

(4) This is an optional section where you can give more specific instructions about your wishes.

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 (Initialhydration.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 with drawn,

(b) give more specific instructions about your wishes concerning life-sustaining treatment or artificially administered nutrition and hydration if you have a ter minal condition, are persistently unconscious, or have an end-stage condition, or

(c) do both of these:

If you choose to, write your specific instructions here.

Initial here only if you have written specific instructions.

Initial

Part II: Appointment of Health Care Proxy

This second part of your Oklahoma Advance Directive for Health Careform concerns the health care proxy that we discussed earlier in this guide. Remember this person will serve as your representative to make health care choices if you are unable to do so. This person can legally have access to your medical information as well as make health care decisions, talk with your doctors, agree to or refuse treatments, or admit you to another facility or to hospice. When making these decisions, your health care proxy is legally bound to follow the instructions you chose in the Living Will section of the Advance Directive for Health Care. Oklahoma’s Advance Directive form allows you to choose one health care proxy and an alternate health care proxy in the event your first choice is unable to do so. If your first choice is your age or older, you may want to choose someone younger as your alternate.

Your health care proxy must be at least 18-years old and of sound mind. This should be someone that you can share your wishes with and trust that they will honor these wishes. Usually a spouse or adult child is chosen as the proxy but sometimes they may feel like they cannot make difficult decisions. In this case, you can choose another family member or a trusted friend. Once you have chosen your proxies, make sure that you discuss your wishes and that there is a clear understanding about what treatment you prefer. It would also be helpful to discuss your wishes with your family and loved ones. This will help to prevent any disputes among your loved ones.

Below is an example of part two of your form.

In this section, you can name a trusted person and an alternate person to make health care decisions for you if you are unable to do so.

Write the first and last name of your health care proxy.

Write the first and last name of your alternate proxy.

You will also have a space to put the address and phone number for your proxies.

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 health care proxy is authorized to make whatever health care decisions I could make if I were able, except that decisions regarding life-sustaining treatment and artificially administered nutrition and hydration can be made by my health care proxy or alternate health care proxy only as I have indicated in the foregoing sections.

If I fail to designate a health care proxy in this section, I am deliberately declining to designate a health care proxy.

Part III: Anatomical Gifts

The third section of your Advance Directive form allows you to choose if you wish to donate your entire body or body parts for research or transplantation.

Organ and tissue donation will NOT affect the medical care that you receive when you are alive and will only occur after death.

There are many people waiting for organ transplants due to illness or injury. You are never too old to be an organ or tissue donor, and it will NOT affect the medical care that you receive. An organ donor can still have an open casket at a funeral and be buried.

Medical schools and research organizations study bodies to understand disease and better educate students. In most cases, you cannot donate your body for research if you choose to be an organ donor for transplant. Bodies donated for research will eventually be creamated, and you may request that your ashes be returned to your family. If you choose to donate your body, you should contact the organization in advance to make arrangements.

Below is an example of part three of your form.

III. Anatomical Gifts

Optional Section: Anatomical

InitialGifts

next to transplantation if you want to be an organ donor.

Initial next to therapy if you want to donate for therapy.

Initial next to advancement of medical science and/or dental science if you want to donate your body or body parts for research or education.

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

_____ Therapy

_____ 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:

Initial here if you want to donate your whole body.

Initial here if you want to choose spe cific parts of your body to donate and then initial next to each part that you would like to donate.

_____ My entire body

Or

_____ The following body organs or parts: (parts are listed on the form with a space beside them to initial)

The fourth section of your Advance Directive for Health Care form gives you information about your choices and filling out your form. Please read this information and ask a member of your health care team if you have any questions.

Part V: Execution

The last section of your Advance Directive for Health Care is where you sign your form and where two witnesses must sign with you. Your form does NOT need to be notarized. However, you must sign the form in front of your two witnesses for the form to be valid. Your two witnesses must be at least 18 years old and should not be related to you or inherit from you upon your death. If you do not have two people to witness you sign, you can bring the completed form with you to your doctor visit and members of our health care team can serve as your witnesses.

Step 5

Share your Advance Directive

Once you have completed your Oklahoma Advance Directive for Health Care form, it is important to take a few more steps:

• Make several copies of your completed form. You should keep one for yourself where it can be easily found. Provide a form to each of your health care proxies. Take a copy to your doctor and your hospital so that it may be placed in your medical record. If you live in a nursing home or assisted living facility, give a copy to staff so that it can be a part of your medical file.

• Discuss your wishes with your loved ones who will be involved if you are injured or have a serious illness. Answer questions and explain your values so that they may understand your wishes. Let them know the names of your health care proxies as well.

Always keep this information in an easy-to-find location, in case of an emergency.

Step 6 Review and Update Your Advance Care Plan

It is a good idea to review your form at least once a year or when you have a major life event. Remember the Five D’s:

• Decade: You should review your form as you begin a new decade in life.

• Death: You should review when a loved one dies, especially if that person is your Health Care Proxy or alternate.

• Divorce: You should review if you go through a divorce or other life change.

• Diagnosis: You should review if you or your health care proxies is diagnosed with a serious medical condition.

• Decline: You should review if your health condition declines (gets worse), especially if you are unable to live by yourself. This applies to your health care proxies as well.

Making Changes to Your Form

You can change your mind and make changes to your Advance Directive for Health Care form at any time. This includes voiding the entire document or making changes by crossing out portions and making changes. If you want to void the entire form, you should write “I Revoke” on each page and keep it for your records. You should also let your health care proxies and doctors know that you have decided to void the form.

The best way to make changes is to complete a new form. When this form is completed, it automatically voids your first directive. Tear up the old forms and make sure to give your new form to your health care proxies and doctor.

Tell your health care proxy about any changes to your Advance Care Plan.

Oklahoma Advance Directive for Health Care

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

I. Living Will

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, pursu ant to the Oklahoma Advance Directive Act, to follow my instructions as set forth below:

(1) If I have a terminal condition, that is, an incurable and irreversible condition that even with the admin istration of life-sustaining treatment will, in the opinion of the attending physician and another physi cian, 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 adminis tered 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 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 at tending 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 adminis tered 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 if applicable)

_____ See my more specific instructions in paragraph (4) below.

If I have an end-stage condition, that is, a condition caused by injury, disease, or illness, which re sults in severe and permanent deterioration indicated by incompetency and complete physical depen dency 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 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 medical treatment, 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 health care proxy is authorized to make whatever medical treatment decisions I could make if I were able, except that deci sions regarding life-sustaining treatment and artificially administered nutrition and hydration can be made by my health care proxy or alternate health care proxy only as I have indicated in the foregoing sections.

If I fail to designate a health care proxy in this section, I am deliberately declining to designate a health care proxy.

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:

Death means either irreversible cessation of circulatory and respiratory functions or irreversible cessa tion of all functions of the entire brain, including the brain stem. If I initial the "yes" line below, I specifi cally donate:

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, life-sustaining 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 _____.