This required section states the Declarant's (the person who the Advance Directive is being created for) intention to make an advance directive. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-sustaining procedures or treatment will be withheld or withdrawn. Press [Ctrl+F1] for more information.
This optional section allows the Declarant to request all life-sustaining procedures or treatment be withdrawn in the event that the Declarant is persistently unconscious. Press [Ctrl+F1] for more information.
This required section states the Declarant's preferences on whether artificially administered nutrition and hydration should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This required section allows the Declarant to designate which organs, tissues, or parts the Declarant desires to donate at the Declarant's death. Press [Ctrl+F1] for more information.
This optional section designates a "Proxy" to make health care decisions if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Advance Directive if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This optional section allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This required section provides an opportunity for the Declarant to request that the provisions of this document be honored. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
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Advance Health Care Directive
ADDIOK
The Oklahoma Advance Directive document allows a person to state health care preferences, and designate a person who will have authority to make health care decisions for the person, if the person is unable to do so.
Enter the Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record. An Advance Directive states the Declarant's intentions regarding life-sustaining procedures or treatments if he/she is in a terminal condition or coma. Press [Ctrl+F1] for more information.
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! Declaration Section (1 of 12)
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:
Enter the Declarant's name or edit the information as desired. Use the P.I. Manager to select and paste a record. An Advance Directive states the Declarant's intentions regarding life-sustaining procedures or treatments if he/she is in a terminal condition or coma. Press [Ctrl+F1] for more information.
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! Life Support Section (2 of 12)
[The Declarant must sign this information to authorize withdrawal or withholding of life-sustaining treatment if the Declarant suffers a terminal condition. Access Document Information for an explanation of a terminal condition.]
!. 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, 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 signature. I understand that I will be given treatment that is necessary for my comfort or to alleviate my pain.
If I have a terminal condition, 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 have an incurable and irreversible condition that even with the administration of life-sustaining treatment will cause my death within six (6) months.
________________________________________
Declarant Signature
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! Optional Coma Section (3 of 12)
If I am persistently unconscious I direct that life-sustaining treatment shall be withheld or withdrawn if such treatment will only serve to maintain me in an irreversible condition, as determined by my attending physician and another physician, in which thought and awareness of self and environment are absent.
________________________________________
Declarant Signature
Enter an X if to withhold or withdraw such treatment will only maintain you in a "persistently unconscious" state, as determined by your attending physician and another physician. The Declarant must sign this instruction to authorize the withholding of life-support. Press [Ctrl+F1] for more information.
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! Nutrition Section (4 of 12)
[The Declarant must sign this instruction to authorize withdrawal or withholding of artificial nutrition and hydration if the Declarant suffers a terminal condition or permanent coma. Access Document information for an explanation of this topic.]
I understand that the subject of the artificial administration of nutrition and hydration (food and water) is of particular importance if I have a condition described above. I understand that if I do not sign this paragraph, artificially administered nutrition (food) and hydration (water) will be administered to me. I further understand that if I sign this paragraph, I am authorizing the withholding and withdrawal of artificially administered nutrition and hydration.
______________________________________
Declarant Signature
*AOK05
! Organ Donation Section (5 of 12)
[The Declarant must sign this section to make an anatomical gift.]
!. ANATOMICAL GIFTS
I direct that at the time of my death my entire body or designated body organs or body parts be donated for purposes of transplantation, therapy, advancement of medical or dental science or research or education pursuant to the provisions of the Uniform Anatomical Gift Act. Death means either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem. I specifically donate:
! My entire body; or
! The following body organs or parts:
! lungs
! liver
! pancreas
! heart
! kidneys
! brain
! skin
! bones/marrow
! bloods/fluids
! tissue
! arteries
! eyes/cornea/lens
! glands
! [other] !
! [ ] My entire body; or
! [X] My entire body; or
! [ ] The following body organs or parts:
! [X] The following body organs or parts:
! [ ] lungs
! [X] lungs
! [ ] liver
! [X] liver
! [ ] pancreas
! [X] pancreas
! [ ] heart
! [X] heart
! [ ] kidneys
! [X] kidneys
! [ ] brain
! [X] brain
! [ ] skin
! [X] skin
! [ ] bones/marrow
! [X] bones/marrow
! [ ] bloods/fluids
! [X] bloods/fluids
! [ ] tissue
! [X] tissue
! [ ] arteries
! [X] arteries
! [ ] eyes/cornea/lens
! [X] eyes/cornea/lens
! [ ] glands
! [X] glands
! [ ] other: _____________________
! [X] other: !
________________________________________
Declarant Signature
Enter an X if the Declarant wishes to donate his or her body for scientific study. It is recommended that a separate agreement for such donation be made between the Declarant and the institution to which the body will be donated. Press [Ctrl+F1] for more information.
Enter an X if the Declarant wishes to make gifts of body organs or other body parts upon the Declarant's death. Press [Ctrl+F1] for more information.
Enter an X if the Declarant wishes to donate lungs at death.
Enter an X if the Declarant wishes to donate the liver at death.
Enter an X if the Declarant wishes to donate the pancreas at death.
Enter an X if the Declarant wishes to donate the heart at death.
Enter an X if the Declarant wishes to donate kidneys at death.
Enter an X if the Declarant wishes to donate the brain at death.
Enter an X if the Declarant wishes to donate skin at death.
Enter an X if the Declarant wishes to donate bones/marrow at death.
Enter an X if the Declarant wishes to donate blood or other body fluids at death.
Enter an X if the Declarant wishes to donate tissue at death.
Enter an X if the Declarant wishes to donate arteries at death.
Enter an X if the Declarant wishes to donate eyes/cornea or lens at death.
Enter an X if the Declarant wishes to donate glands at death.
Enter an X if the Declarant wishes to specify other organs, tissues, or parts to be donated at the Declarant's death. This option may also be selected to donate "any needed organs, tissues, or parts" and may include any exceptions the Declarant wishes to make.
Enter a description of the organs, tissues, or other parts to be donated upon the Declarant's death. For example, intestines, blood vessels, or musculoskeletal structures (i.e., tendons and ligaments). The Declarant may also specify any needed organs, tissues, or parts with any exceptions noted.
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! Optional Proxy Section (6 of 12)
!. 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 Rights of the Terminally Ill or Persistently Unconscious Act, to follow the instructions of:
Proxy Name: !
Proxy Address:
Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
whom I appoint as my health care proxy. If my health care proxy is unwilling to serve, I appoint:
Alternate
Proxy Name: !
Proxy Address:
Street 1: !
Street 2: !
City: !,
State: !
Zip Code: !
! ___________________________________
___________________________________
___________________________________
___________________________________
Country: !
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 decisions regarding life-sustaining treatment can be made by my health care proxy only as I indicate in this document. If there is a conflict between my health care proxy's decision and my Living Will, my Living Will shall take precedence, unless I indicate otherwise.
________________________________________
Declarant Signature
Enter an X to include a section regarding the appointment of a Health Care Proxy. A Proxy has the authority to make health care decisions for the Declarant if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
Enter the name of the Proxy or use the P.I. Manager to select and paste a record.
Enter the Proxy's street address or edit the information as desired.
Enter the Proxy's extended street address or edit the information as desired.
Enter the Proxy's city or edit the information as desired.
Enter the Proxy's state/province or edit the information as desired.
Enter the Proxy's zip/postal code or edit the information as desired.
Enter an X to include the country in which the Proxy resides, if outside the United States.
Enter the country or edit the information as desired.
Enter the name of the person who will be appointed as the Alternate Proxy if the Proxy is unwilling to serve. Use the P.I. Manager to select and paste a record.
Enter the Alternate Proxy's street address or edit the information as desired.
Enter the Alternate Proxy's extended street address or edit the information as desired.
Enter the Alternate Proxy's city or edit the information as desired.
Enter the Alternate Proxy's state/province or edit the information as desired.
Enter the Alternate Proxy's zip/postal code or edit the information as desired.
Enter an X to include the country in which the Alternate Proxy resides, if outside the United States.
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! Optional Pregnancy Section (7 of 12)
!. OTHER PROVISIONS
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining treatment, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining treatment will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy paragraph. This provision states that the Advance Directive will not be enforced if the Declarant is pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Advance Directive if the Declarant is pregnant. This exception permits enforcement of the Advance Directive if the fetus could not develop to the point of live birth with the continued application of life-sustaining treatment.
Enter an X to provide an exception to the invalidity of the Advance Directive if the Declarant is pregnant. This exception requests that pain or physical harm to the Declarant be considered in determining whether life-sustaining treatment should be withheld or withdrawn.
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! Optional Other Section (8 of 12)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
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! Optional Severability Section (9 of 12)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the space bar to deselect the checkbox. Press [Ctrl+F1] for more information regarding the reasons for including a severability paragraph.
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! Right of Refusal Section (10 of 12)
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 refuse medical or surgical treatment including, but not limited to the administration of any life-sustaining procedures and I accept the consequences of such refusal.
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! Declarant Signature Section (11 of 12)
This advance directive shall be in effect until it is revoked.
I understand that I may revoke this directive at any time.
I understand and agree that if I have any prior directives, and if I sign this advance directive, my prior directives are revoked.
I understand the full importance of this advance directive and I am emotionally and mentally competent to make this advance directive.
Signed this ____ day of _______________, 19___.
________________________________________
Signature
Declarant Name: !
Declarant Address:
City: !
County: ! County
State: !
! Country: !
! SSN: !
! Birthdate: !
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's county/parish or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the Declarant's country, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Advance Directive files.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the birthdate, the health care providers will be assisted in maintaining their Advance Directive files.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
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! Witness Signature Section (12 of 12)
[Carefully review the witness requirements. If this document is not properly witnessed, it may not be enforceable.]
This advance directive was signed in my presence. Each of us is at least eighteen (18) years of age or older, and neither of us is a legatee, devisee or heir at law of the Declarant.
Enter the name of the FIRST Witness or use the P.I. Manager to select and paste a record. The name and address of the Witness may be left blank and be completed when the document is signed. The Witness must be at least eighteen (18) years of age or older, and not be a legatee, devisee, or heir at law of the Declarant.
Enter the First Witness' street address or edit the information as desired.
Enter the First Witness' extended street address or edit the information as desired.
Enter the First Witness' city or edit the information as desired.
Enter the First Witness' state/province or edit the information as desired.
Enter the First Witness' zip/postal code or edit the information as desired.
Enter an X to include the country in which the First Witness resides, if outside the United States.
Enter the country or edit the information as desired.
Enter the name of the SECOND Witness or use the P.I. Manager to select and paste a record. The name and address of the Witness may be left blank and be completed when the document is signed. The Witness must be at least eighteen (18) years of age or older, and not be a legatee, devisee, or heir at law of the Declarant.
Enter the Second Witness' street address or edit the information as desired.
Enter the Second Witness' extended street address or edit the information as desired.
Enter the Second Witness' city or edit the information as desired.
Enter the Second Witness' state/province or edit the information as desired.
Enter the Second Witness' zip/postal code or edit the information as desired.
Enter an X to include the Second Witness' country, if outside the United States.
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