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Your Right To Decide
Oklahoma’s Advance Directive
& Other Health Care Planning Tools
Senior Law
Resource Center
What every Oklahoman needs to know about
planning for incapacity and staying in control
of medical care at the end of life.
Dedicated to Laura Cross, RN, JD, who in both her professional
and personal life did so much to improve end-of-life care for
patients and their families.
Your Right To Decide: Oklahoma’s Advance Directive & Other Health Care Planning Tools was produced in
partnership by the Oklahoma Attorney General’s Task Force To Improve End-of-Life Care in Oklahoma, the
Oklahoma Palliative Care Resource Center, the Senior Law Resource Center and St. John Health System. A
special thanks to Lane Wood for her assistance in researching and writing the guide.
Additional copies of this guide may be ordered from the Senior Law Resource Center, P.O. Box 1408, Oklahoma City, OK 73101, (405) 528-0858, FAX (405) 601-2134, [email protected]
This guide can also be downloaded in PDF format at no cost from www.senior-law.org.
Users are encouraged to reproduce parts or all of this guide for free distribution only.
This project was initially made possible with financial support from the American Bar Association’s Partnership
in Law and Aging Program, a project of the Borchard Foundation Center on Law and Aging and the American
Bar Association Commission on Law and Aging.
Additional funding was provided by the Senior Law Resource Center and by the Hospice Foundation of Oklahoma Affiliated Fund, Inc., an endownment administered by the Oklahoma City Community Foundation. The
Hospice Foundation of Oklahoma Affiliated Fund, Inc. was founded in 1998 to support programs that train and
educate persons providing physical, emotional, social and spiritual care to terminally ill persons and their loved
ones and to educate the public, patients and families concerning the death process.
This guide was one of the outcomes of the Oklahoma Attorney General’s Task Force To Improve End-of-Life
Care in Oklahoma. The Oklahoma Attorney General’s Task Force Report on the State of End-of-Life Health
Care 2005 can be downloaded at www.oag.state.ok.us. Enter “End of Life Report” in the Search box.
1st Printing 2007, 2nd and 3rd Printing 2008, 4th Printing 2009
Table of Contents
Letter from the Attorney General 2
Introduction 3
Medical Treatment Choices 4
Types of Medical Treatment 4
Artificial Life-Support Systems 5
Making Your Wishes Known 7
Thinking and Talking About Your Wishes 7
Your Right To Decide 7
Advance Directive for Health Care 8
Part I: Living Will 8
Part II: Appointment of Health Care Proxy 12
Part III: Anatomical Gifts 12
How To Complete an Advance Directive 14
What To Do With Your Advance Directive 14
How To Change or Revoke an Advance Directive 15
When To Review Your Advance Directive 15
Additional Planning Options 16
Durable Power of Attorney 16
Do-Not-Resuscitate (DNR) Consent 16
Guardianship & Surrogates 17
Guardianship 17
Children at the End of Life 17
Resources 18
Oklahoma Resources 18
National Resources 19
Key Terms 20
Oklahoma Advance Directive for Health Care Form 21
Letter from the Attorney General
Thank you for taking the time to consider carefully your wishes
for health care at the end of life. I am proud that this guide is
available to Oklahomans to inform us about these difficult decisions.
Working to improve end-of-life care is an important part of my
consumer protection role as Oklahoma’s Attorney General. This
issue was the focus of my term as president of the National Association of Attorneys General. In 2004, I formed a task force of
15 legal and health care professionals and asked them to investigate end-of-life care in Oklahoma. The task force was chaired by
myself and three health care experts: Dr. Garry Johnson, M.D.,
University of Oklahoma College of Medicine; Dr. Carole Kenner,
DNS, RNC, FAAN, Dean and Professor of the Oklahoma College
of Nursing; and Linda Edmondson, LCSW.
Over the course of a year, task force members and more than 80 advisory committee members
heard from panels of experts about issues such as advance directives, nursing facilities and hospice. Their findings and recommendations were published in 2005 and have been the impetus
for several important changes in Oklahoma law.
One of the task force’s key recommendations was the development of a consumer guide explaining the medical and legal concepts Oklahomans need to understand in order to make informed choices and to ensure their wishes are honored at the end of life. I am pleased that Your
Right To Decide: Oklahoma’s Advance Directive & Other Health Care Planning Tools has now
been published and is being made available to Oklahoma citizens.
I deeply appreciate the task force chairs, members, advisory committee members and all those
who supported the work of the task force. A special thanks goes out to Jan Slater Anderson,
Linda Edmondson, Catheryn Koss, Annette Prince and Lane Wood who developed this consumer guide. Thanks also to the Borchard Foundation Center on Law and Aging, the American Bar
Association Commission on Law and Aging, the Senior Law Resource Center and the Hospice
Foundation of Oklahoma Affiliated Fund, Inc. for generously providing the funding that made
this guide possible.
Sincerely,
W.A. Drew Edmondson
2
Introduction
No one likes to think about the possibility
of losing capacities or becoming severely
ill. But the more completely you understand
your options and express your own feelings,
the easier it will be to engage the support of
people you love in bringing peace and meaning to the end of your life. Communicating
your preferences about end-of-life treatment
will save your family the heartache of having to make decisions for you without knowing your wishes.
You can decide how to live the last days of
your life, but you must think and talk about
these issues with your loved ones and physician ahead of time. Because it is impossible
to foresee every situation or complication
that might arise, share your values about
what makes life worth living, your views
about life and death and your end-of-life priorities with your family and doctor so they
can respect your wishes in any situation.
In the past, most people died at home after a
short illness under the care of a family physician who could do little more than try to
keep the patient comfortable. Today, death
is often more complicated. Because many
previously terminal illnesses are now treatable with advanced medical treatment, it
is more common for patients to experience
chronic illness over months or years caused
by progressive diseases such as dementia,
heart disease, cancer or stroke.
About This Guide
Even during the later stages of chronic diseases like these, medical science can often
extend a patient’s life. However, patients
suffering from severe chronic pain, dementia
or other conditions that drastically reduce
quality of life may feel the burden of continued treatment is too great. This is the
point when the patient (if capable), doctor
and family need to come together to make
decisions about whether to continue curative treatment or to focus on keeping the
patient comfortable during the remaining
time. These decisions are difficult to make,
but knowing the patient’s wishes can greatly
help to ease this burden.
This guide will help you better understand treatment options, likely side effects and other medical issues that can
arise at the end of life. It also provides
some information to help you think
about and discuss your views, values
and wishes with loved ones and health
care providers. Finally, this guide provides practical information about how
you can make sure that your wishes
are known and carried out.
At the end of this guide are a list of Resources and a Key Terms. There is also
a blank Advance Directive that you may
choose to complete.
The information presented in this guide
is based on Oklahoma law. Each state
has its own laws and forms related to
end-of-life and incapacity issues.
This guide provides general information
and is not intended to serve as legal or
medical advice. Please consult a physician and/or attorney for advice regarding your situation.
3
Medical Treatment Choices
Despite recent advances, the goals of medicine — curing disease, restoring health and
maintaining quality of life — cannot always
be achieved. Understanding end-of-life
treatment options and side effects can help
you decide what you would choose.
Types of Medical Treatment
Acute Care
Acute care is provided in a hospital and
focuses on providing treatment for a shortterm illness or injury until the patient is stabilized or restored to good health. Hospitals
are generally designed to cure illness and
save lives, and the equipment, procedures
and attitudes of the staff often reflect these
goals.
Nursing Facility Care (Nursing Homes)
Nursing facility care usually involves longterm care for patients with severe physical
weakening and impairment. This includes
assistance with personal care activities such
as eating, walking and bathing. Nursing
care also involves coordinated management
of patient care, including social services
and activities. Some nursing facilities offer
specialized care such as services for patients
with Alzheimer’s disease, dialysis for kidney
disease or tube feeding.
Palliative Care
Palliative care is sometimes referred to as
comfort care, advanced illness care or supportive care. The goal of palliative care is to
provide the best quality of life for the patient
and family during the process of illness, dying and bereavement. The focus of palliative
4
care is on making the patient comfortable,
including controlling pain and managing
symptoms, rather than on trying to cure the
underlying disease.
Hospice Care
Hospice care, a type of palliative care, aims
to give a patient and family members a better end-of-life experience by allowing a patient to die at home or in a home-like setting,
striving to make the patient comfortable and
caring for the emotional needs of the patient
and family. Hospice care focuses on relieving the symptoms of persons who are dying
and accepts death as a natural part of life.
Hospice care is provided by a multi-disciplinary team of professionals trained to address not only physical symptoms, but also
psychological and spiritual needs. Nurses,
chaplains and social workers spend time
with the patient and the family, often providing support services and bereavement counseling to loved ones for up to a year after the
patient dies.
If you are a Medicare beneficiary, hospice is a covered benefit under Part
A. Most private insurance plans offer
a hospice benefit. If insurance coverage is unavailable or insufficient, you
and your family can discuss private
pay and payment plans. Many hospice
providers will waive or reduce fees for
patients who are unable to pay for services. Hospices are required to provide
care for all eligible patients regardless
of their ability to pay.
Medical Treatment Choices
If you need assistance finding hospice care, your physician or hospital
discharge planner can help you locate
hospices in your area. Hospice care
providers are also listed in the phone
book. Several websites that offer directories of hospice providers are listed
in the Resources section at the back of
this guide.
Artificial Life-Support Systems
Artificial life-support systems are machines
that assist the body to function if the body’s
natural systems fail. The basic bodily functions that can be sustained artificially include the ability to breathe, to take in nourishment and fluid and to eliminate waste.
Mechanical Ventilation (Respirator)
When a person cannot breathe independently, a machine called a respirator is used to
take over breathing. While a respirator can
save the life of a patient recovering from an
illness or accident, it cannot restore a patient’s lungs or prevent the death of a person
with an incurable, fatal disease or condition.
Patients on respirators cannot speak and
have difficulty coughing, so fluids can build
up in the lungs, increasing the risk of pneumonia.
Artificially Administered Nutrition and Hydration (Tube Feeding)
When a person cannot eat or drink by
mouth, tube feeding is a method of artificially delivering liquids and nutrients. For
short-term feeding, a tube is inserted through
the patient’s nose into the stomach. For
long-term feeding, a tube may be surgically
inserted directly into the stomach or intestines. Another form of long-term artificial
feeding is called total parenteral nutrition, or
TPN. Liquid nutrients are given through a
tube that goes directly into a large vein near
the patient’s heart.
Although tube feeding is a short-term substitute for eating by mouth, studies show
that tube feeding does not extend life. Some
tube feeding procedures can be uncomfortable and may increase the risk of infection
and other complications such as irritation
where the tube is inserted, diarrhea, bloating
or possible liver damage from TPN. Tubes
can easily become dislodged and must be
repeatedly replaced.
Long-Term Dialysis
Kidneys are internal organs that filter and
clean the blood. When kidneys fail, waste
and excess fluid accumulate in the blood.
Dialysis can take over the function of the
kidneys and extend a patient’s life. However, complications and infections can occur. Without a kidney transplant, long-term
dialysis often must be continued for the
remainder of the person’s life. The typical
dialysis patient receives three treatments a
week, and each treatment takes from three to
five hours. Dialysis requires a strong, ongoing commitment from the patient, the family and health care professionals. It is not a
“cure” for kidney disease; it is a substitute
for normal kidney function.
5
Medical Treatment Choices
Cardiopulmonary Resuscitation (CPR)
When a person stops breathing and his or
her heart stops beating, this is called cardiopulmonary arrest. Once the heart stops beating, a person will die within a few minutes
unless immediate action is taken. Cardiopulmonary resuscitation (CPR) can be used
in an emergency to try to restart heartbeat
and breathing. CPR is usually considered to
be appropriate when the chance of recovery
is reasonably good.
CPR is rarely life-saving when cardiac arrest
is due to advanced age or serious illness.
CPR should not be administered to patients
who have indicated they do not want it. It
may also not be appropriate for patients who
are very unlikely to recover.
Other Life-Sustaining Treatment
In addition to the life-support systems and
the procedures described above, any medication, procedure or treatment that is necessary
to sustain a person’s life is a life-sustaining
treatment. Examples are cardiac medications, blood pressure medicine, pacemakers,
chemotherapy and antibiotics.
6
Making Your Wishes Known
Thinking and Talking About Your
Wishes
Determining your end-of-life wishes involves thinking about the fundamental questions of life. What are your spiritual beliefs?
What gives you joy and what makes you
fearful? Ultimately, what makes life worth
living for you?
It is important to reflect on what you would
want to happen if you lost capacity or became severely ill. Remember, there is no
right answer other than the answer that is
right for you.
An important part of this process is talking to loved ones about your wishes. While
many people find it difficult to start a conversation about the end of life, having the
conversation can be a gift to those who love
you. Knowing your preferences will ease
their burden of making difficult decisions by
giving them the peace of mind of knowing
they honored your wishes.
If you are met with resistance, do not give
up. If friends and family are not ready to
talk, give them a copy of this guide and use
it as a starting point for the discussion. Emphasize how important it is to you that these
issues are talked about in advance. If you do
not feel comfortable insisting, find someone
who is willing to advocate on your behalf to
encourage the discussion.
Your Right To Decide
If you are of sound mind and at least 18
years old, you have the right to decide what
Think about whether you would want
to have life-sustaining treatment if:
• the treatment would cause pain and
was not likely to succeed
• the treatment would prolong your
life, but you would be in chronic
pain
• you could no longer control bodily
functions
• you could no longer recognize family members
• you were bedridden
• you were unable to communicate
• you required around-the-clock care
types of medical treatment you do and do
not want. Before you make a decision about
medical treatment, you have the right to
receive the information you need to understand your physical condition and the risks,
benefits and alternatives to a proposed treatment. You may express your medical treatment decisions orally or in writing.
You may also express your wishes orally or
in writing in case you are unable to make
decisions for yourself in the future. The
following sections of this guide explain the
different options for expressing your wishes
in advance. Completing an Advance Directive for Health Care is the best way.
It is important for you to know that Oklahoma law presumes you want to be resuscitated if your heart stops or you stop breathing,
and you want to receive tube feeding when
you cannot take food by mouth unless you
have expressed your wishes not to receive
such treatment.
7
Advance Directive for Health Care
An Advance Directive for Health Care is a
document used to communicate your health
care decisions if you become unable to
express those wishes directly. You must be
at least 18 years old and of sound mind to
complete an Advance Directive.
Oklahoma’s Advance Directive form has
three parts: Living Will, Appointment of
Health Care Proxy and Anatomical Gifts.
These three parts are described in more detail below.
Part I: Living Will
The first section of Oklahoma’s Advance
Directive allows you to express your treatment preferences if you develop a terminal
condition, become persistently unconscious
or suffer from an end-stage condition.
A Terminal Condition is caused by an illness or injury that is incurable and cannot be
reversed. In order to be considered terminal,
two physicians must agree that, even with
medical treatment, death will likely occur
within six months.
A Persistently Unconscious State or Persistent Vegetative State (PVS) is a deep
and permanent unconsciousness. Patients
may have open eyes, but they have very
little brain activity and are capable only of
involuntary and reflex movements. Confirming a diagnosis of PVS requires many
tests that may take several months. Unlike
patients with other types of coma, patients in
PVS will never “wake up” and regain health.
Patients in PVS cannot feel hunger, thirst or
pain.
8
An Advance Directive gives you the
chance to:
• decide in advance whether to
choose or forego life-sustaining
treatment, including tube feeding
• appoint a health care proxy to make
medical decisions on your behalf
• elect to donate body parts or your
entire body for transplantation or
research
An End-Stage Condition is a condition
caused by injury, disease or illness that
results in a gradual and irreversible loss
of mental and physical abilities. A person
with an end-stage condition may be unable
to speak or walk, may be unable to control
bowel and bladder functions, may have
decreased appetite and difficulty swallowing and eating, and may not recognize loved
ones. Examples of end-stage conditions
include dementia caused by Alzheimer’s disease or severe stroke. Medical treatment of
this condition will not improve the patient’s
chances of recovery.
For each of these three conditions, you can
choose to receive all life-sustaining treatment, only tube feeding or no life-sustaining
treatment. See the previous section Medical Treatment Choices for more information
about life-sustaining treatment, including
tube feeding.
Other Instructions
The Advance Directive form gives you the
option of writing more specific instructions,
including describing other conditions in
Advance Directive for Health Care
which you would or would not want lifesustaining treatment. Things you may want
to consider addressing in this space include:
• Pain Management – You can specify the
level and type of pain management care
you would like to receive. For example,
you may want to authorize the administration of pain medications, including
narcotics, without regard to risk of addiction or side effects that may hasten death.
• Pregnancy – In the event that you are
pregnant, you will be provided with lifesustaining treatment, including artificially
administered hydration and nutrition,
unless you specifically authorizes in your
own words such treatment to be withheld
or withdrawn even if pregnant.
• HIPAA Authorization – If you are concerned that your health care proxy may
have difficulty accessing your medical
information, you can write, “I authorize
my protected health information in my
health record to be disclosed to my health
care proxy, who shall be considered a
personal representative for HIPAA purposes.”
• Particular Procedures – You can authorize or decline particular medical procedures or treatments such as blood transfusions, dialysis or antibiotics.
• Time Limit on Treatment – You can
authorize life-sustaining treatment to be
continued for a specific period of time
and authorize its withdrawal after that
time period. For example, you can authorize life-sustaining treatment until all
of your children have the opportunity to
travel to you.
A patient who chooses not to receive
life-sustaining treatment still receives
palliative care to control pain and keep
the patient as comfortable as possible.
• Exceptional Circumstances – You can
specify particular circumstances when
you would want different medical treatment, such as to allow time for a religious rite or family members to arrive.
• Authorization of Hospice – You can
request that you be placed on hospice as
soon as it becomes appropriate.
• People You Do Not Want Involved
–You may wish to name people whom
you do not want involved in making decisions on your behalf.
The sample form on the next two pages illustrates how to complete the Living Will
section of the Advance Directive form.
If you do not complete the Living Will
section of the Advance Directive, your
health care proxy may make these
decisions on your behalf based on what
he or she believes you would have
wanted.
If you wish to expressly leave these
decisions up to your health care proxy,
you may write, “I authorize my health
care proxy to withhold or withdraw lifesustaining treatment, including artificial
hydration and nutrition, if he/she determines that I would decline such treatment under the circumstances.”
9
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 feeding.
Initial here only if you have
written instructions regarding treatment or tube
feeding in the event of a
terminal illness.
(2) Choose whether you
would want life-sustaining
treatment and/or tube feeding if you become persistently unconscious.
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.
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.
Initial here if you DO want
BOTH life-sustaining treatment and tube feeding.
_____ 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 here only if you have
written instructions regarding treatment or tube feeding in the event you become
persistently unconscious.
(Initial only if applicable)
10
_____ 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.
(3) Choose whether you
would want life-sustaining
treatment and/or tube feeding if you have an incurable
condition causing you to be
incompetent and completely
dependent.
Initial here if you DO NOT
want life-sustaining treatment, but you DO want
tube feeding.
_____ I direct that my life not be extended by life-sustaining treatment, including
artificially administered nutrition and hydration.
Initial here if you DO NOT
want life-sustaining treatment and you DO NOT want
tube feeding.
_____ 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 here if you DO want
BOTH life-sustaining treatment and tube feeding.
(Initial only if applicable)
Initial here only if you have
written instructions regarding treatment or tube feeding in the event you have
an end-state condition.
_____ 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
(4) This is an optional section where you can give
more specific instructions
about your wishes. See
pages 8-9 for ideas and
suggested language.
(c) do both of these:
____________________________________________________________________
____________________________________________________________________
If you chose to, write your
specific instructions here.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
_______
Initial
Initial here only if you have
written specific instructions.
11
Advance Directive for Health Care
Part II: Appointment of Health Care
Proxy
When you are unable to do so, your health
care proxy is the person who will make all
health care decisions (not just life-sustaining
treatment decisions) that you would make if
you were able. This includes having access
to your medical information and talking with
the health care providers about treatment options. It may include seeking second opinions from other physicians or consenting
to or refusing medical tests or treatments,
including life-sustaining treatment. It also
may include decisions about placing you
in a health care facility, selecting hospice,
or transferring you into the care of another
physician.
When deciding who to name as your
health care proxy, consider the following criteria:
• Can the person legally act as your
health care proxy?
• Is the person willing?
• Will the person be available when
needed?
• Will the person be able to carry out
your wishes?
• How well does this person know you
and understand your values?
• Is this someone you trust?
• Is this person willing to talk with
you about sensitive issues?
• Will this person be able to ask medical personnel questions and advocate on your behalf?
• Will this person be able to handle
conflict?
12
When making these decisions, your health
care proxy is bound to follow the instructions you gave in the Living Will section
of your Advance Directive. He or she must
also honor what is known about your wishes
when making decisions on your behalf.
Oklahoma’s Advance Directive form allows
you to choose one health care proxy and one
alternate health care proxy. Your health care
proxy must be at least 18 years old and of
sound mind. He or she should also be someone you trust, who knows you well and who
will honor your wishes. Usually a spouse
or adult child is appointed. However, sometimes a spouse or adult child may not feel
able to make difficult decisions. If your first
proxy is your age or older, you may want to
choose a younger person as your alternate
proxy.
Once you choose your proxies, make sure
they know your wishes and understand the
values that guide your thinking about life,
death and dying. Be sure there is a clear
understanding between you and your proxies
about what treatment you would prefer.
Part III: Anatomical Gifts
The third section of the Advance Directive
form gives you the option of donating your
entire body or designated body parts for
transplantation or research.
You or your family will not be charged
for organ or tissue donation. You or
your estate may still be responsible for
your other medical and funeral costs.
Advance Directive for Health Care
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.
Here you can name a person
and an alternate person to
make health care decisions for
you if you are unable to.
Write the first and last name of
your health care proxy.
Write the first and last name of
your alternate proxy.
If I fail to designate a health care proxy in this section, I am deliberately declining to designate a health care proxy.
Medical schools and research facilities study
bodies to educate students and better understand the effects of disease. Generally,
you cannot donate your body for medical
research if you also wish to donate your
organs for transplantation.
You are never too old to be an organ or tissue donor. Each donor will be evaluated for
suitability when the occasion arises. Some
medical conditions will make a potential donor ineligible, including HIV/AIDS, active
cancer or systemic infection.
Bodies donated for research will eventually be cremated by the institution. You may
request that the ashes (called cremains) be
returned to your family, scattered by the
institution or included in a group interment.
The body cannot be returned for burial.
Organ and tissue donation will only occur
after death. Death is defined as either the
point at which all circulation and breathing
functions have permanently stopped or at the
time all brain functions have permanently
stopped. Being an organ or tissue donor will
in no way affect the medical care you receive while you are alive.
There are thousands of people on waiting
lists for organ transplants. Skin, bone marrow and even eyes can also be donated to
help people suffering from illness or injury.
Be aware that it may be necessary to place a
donor on a breathing machine temporarily to
keep blood flowing to the organs. An organ
donor can still have an open casket and be
buried. Most religions support organ and tissue donation as a charitable act.
If you would like to donate your body
to science, you should contact the
medical organization of your choice to
make arrangements in advance. Information about how to make these
arrangements can be found in the
Resources section at the back of this
guide.
13
Advance Directive for Health Care
Part III Anatomical Gifts is
an optional section.
Initial next to transplantation if you want to be an
organ donor.
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.
Initial here if you want to
donate your entire body.
Initial here if you want to
specify which parts you
want to donate.
Only if you have opted
to specify which parts to
donate, initial next to each
part that you would like to
donate.
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
_____ 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
_____ blood/fluids
_____ brain
_____ pancreas
_____ arteries
_____ bones/marrow
_____ kidneys
_____ liver
_____ tissue
_____ skin
_____ heart
_____ eyes/cornea/lens
How To Complete an Advance
Directive
In order for your doctors or hospital workers to be legally required to follow your
Advance Directive, it must meet certain
requirements. You must be of sound mind
and at least 18 years old when you complete
the Advance Directive.
Mark each of your choices with your initials
(do not use checkmarks). Your Advance Directive must be signed by you and two witnesses who are 18 years of age or older, are
14
not related to you and will not inherit from
you. You do not need an attorney to execute
an Advance Directive. An Advance Directive does not need to be notarized.
What To Do With Your Advance
Directive
Once you have completed your Advance Directive, keep a copy in a place where it can
be easily found. Consider putting one copy
on your refrigerator and another copy in
your glove compartment. Do not keep your
Advance Directive in a safe deposit box or
Advance Directive for Health Care
locked away. You may also want to carry a
card indicating you have an Advance Directive, where a copy can be located and the
contact information for your physician and
health care proxies.
Give copies of your Advance Directive to
your health care proxy and alternate proxy.
You may want to give them any notes you
have made about your wishes.
Give a copy to your physician who will
make it a part of your medical record. Make
sure your physician is willing to comply
with your wishes. Oklahoma law requires
physicians and other health care providers to
promptly inform you if they are not willing
to comply. You may want to give a copy to
your attorney, if you have one.
If you live in an assisted living facility or
nursing home, give a copy to a staff member
who can make it a part of your file.
Advance Directive forms are widely
available at no charge from hospitals,
nursing homes, hospice organizations,
home health agencies and Area Agencies on Aging. Oklahoma Advance Directive forms can also be downloaded
for free from the following websites:
• www.okbar.org
• http://okpalliative.nursing.ouhsc.edu
• www.senior-law.org
Printed Advance Directive forms can be
ordered at no charge from the Department of Human Services by fax at
(405) 524-9633.
How To Change or Revoke an
Advance Directive
The best way to make changes to an Advance Directive is to complete a new form.
You may attach written changes to the
original document if those changes are also
signed and witnessed in a similar manner
as an Advance Directive form. Do not alter
the original document. Altering the original
document may invalidate it because those
changes would not be witnessed as required.
You can revoke all or part of your Advance
Directive at any time and in any manner that
indicates your intention to revoke. Tell your
attending physician that you revoked your
Advance Directive and to make your revocation part of your medical record. It is best
to document your revocation by writing “I
Revoke” across each page and keeping it for
your records. Tell everyone who has a copy
that it has been revoked and ask them to
destroy their copies.
Completing a new Advance Directive automatically revokes your old one. Remember
to give copies of your new Advance Directive to your physician, proxies and the other
people listed above.
When To Review Your Advance
Directive
Review your Advance Directive every few
years, especially after a major life change
such as the death of a loved one, divorce or
a diagnosis of a serious medical condition.
If your current Advance Directive no longer
reflects your wishes, complete a new one.
15
Additional Planning Options
Durable Power of Attorney
A Durable Power of Attorney is a legal
document that gives another person, called
an “attorney-in-fact,” the authority to make
decisions and take actions on your behalf in
the event you are unable to act for yourself.
Depending on how it is drafted, a Durable
Power of Attorney can grant the authority to
handle business, financial, personal care, and
most medical matters. It is a useful incapacity planning tool that can prevent the need
for a guardianship.
However, a Durable Power of Attorney
cannot give someone the authority to make
life-sustaining treatment decisions. Only an
Advance Directive for Health Care can do
that. Therefore, a Durable Power of Attorney
cannot be used in place of an Advance Directive for Health Care.
The same considerations used to choose
a health care proxy apply to choosing an
attorney-in-fact. (See page 12.) If you complete both an Advance Directive and a Durable Power of Attorney, it is strongly recomIf you become unable to make decisions regarding your medical treatment
and have not executed an Advance
Directive indicating your wishes or appointing a Health Care Proxy, your physician may consult with your immediate
family in making decisions on matters
of routine care. However, Oklahoma
law severely limits others’ ability to
refuse or withdraw life-sustaining treatment or tube feeding on your behalf.
16
mended that you name the same person(s).
Generally, it is a good idea to consult an
attorney about drafting and executing a Durable Power of Attorney.
Do-Not-Resuscitate (DNR) Consent
A person may refuse CPR by consenting to
a “Do Not Resuscitate” (DNR) order. If you
know that you would not want to be resuscitated under any circumstances if your heart
stopped or you stopped breathing, you can
sign a DNR Consent form. A DNR takes
effect immediately when it is signed. Therefore, it is a near death document.
Your doctor or other health care professional
can provide you with a DNR Consent form.
DNR may also be documented by wearing a
DNR necklace or bracelet.
If a DNR is in place, an emergency responder may not perform chest compressions,
administer cardiac resuscitation drugs or use
electric shock to restore a heartbeat, nor may
they breathe for you or insert a tube into
your wind pipe to restore breathing. Emergency responders may still clear airways, administer oxygen, position for comfort, splint
injured bones, control bleeding, provide pain
medication, provide emotional support and
contact a hospice or home health agency if
either has been involved in your care.
If you change your mind after completing a
DNR Consent form, you can easily revoke
your consent by letting your family or physician know or by destroying the consent
form, necklace or bracelet.
Guardianship & Surrogates
Guardianship
If you become incapacitated and do not have
an Advance Directive or Durable Power
of Attorney appointing a proxy decision
maker, the court may be asked to appoint a
legal guardian. A guardian is given power
to make decisions about the care of another
person, called the “ward.”
Guardianships have several major disadvantages. In almost all cases, an attorney is
needed to assist with the guardianship petition process. The appointment process is often slow and costly for the patient or family.
The guardian is generally required to submit
reports to the court regarding the ward’s
condition and seek the court’s permission for
major decisions.
The powers of a guardian include only those
granted by the court and can never include
the power to withhold or withdraw life-sustaining treatment unless the ward executed
an Advance Directive when competent or
the judge issues a specific order at the time
the treatment decision must be made. However, a guardian can be granted the power to
sign a DNR Consent form.
For most adults, legal guardianship is an
option of last resort for making health care
decisions. The best way to ensure that your
medical treatment wishes are honored is to
complete an Advance Directive.
themselves. Decisions for children have to
be made by surrogate decisionmakers. In
most cases, parents or other close family
members may make these decisions for the
child.
Surrogates can make decisions based on
formal statements signed by the child, an
understanding of the child’s wishes or substituted judgment based on what the child
typically would have done in similar situations. In the case of infants and toddlers, the
surrogate may independently determine the
best interests of the child.
Generally, if the child is at least 7 or 8 years
old and capable, it is best to allow the child
to participate in treatment discussions. Even
though the child may not be old enough to
understand all treatment options, the child
should be allowed the opportunity to consent to proposed treatment. Teenagers may
have an even greater ability to participate
in planning their care and in understanding their treatment options. Minors who are
old enough to understand must be consulted
regarding a DNR order.
In cases where the family wants to reduce
or refuse care when there is a reasonable
hope of improvement or survival, Oklahoma
Child Protective Services and the law provide for advocacy on behalf of the child’s
interests. A guardian ad litem may be appointed by the court to represent the child’s
interests.
Children at the End of Life
Children do not have the same rights as
adults to make health care decisions for
17
Resources
Oklahoma Resources
Department of Human Services, Aging
Services Division
(800) 211-2116
www.okdhs.org
Legal Aid Services of Oklahoma
OKC Senior Law Project (405) 557-0014
OKC (405) 488-6825 or (800) 421-1641
Tulsa Hotline (888) 534-5243
www.legalaidok.org
LifeShare Transplant Donor Services of
Oklahoma
(800) 826-5433
Lion’s Eye Bank
(405) 557-1393
Oklahoma Attorney General’s Office
(405) 521-3921 or (918) 581-2885
www.oag.state.ok.us
Oklahoma Bar Association
(405) 416-7000 or (800) 522-8065
www.okbar.org
Oklahoma Department of Health, Long
Term Care Services
(405) 271-6868
www.health.state.ok.us/program/ltc
Oklahoma Hospice and Palliative Care
Association
(405) 606-4442, (866) 459-4152 or
(800) 356-0622
www.okhospice.org
18
Oklahoma Mental Health and Aging
Coalition
www.omhac.org
Oklahoma Palliative Care Resource
Center
http://okpalliative.nursing.ouhsc.edu
Oklahoma State University College
of Osteopathic Medicine Body Donor
Program
(918) 561-8446
Project for Optimal EMS for Seniors
www.POEMSS.org
Senior Information Line
(800) 211-2116 (or dial 211)
Senior Law Resource Center
(405) 528-0858
www.senior-law.org
Sooner Palliative Care Institute
(405) 271-1491 ext. 49160
www.nursing.ouhsc.edu/SPCI
University of Oklahoma Health Sciences
Center Willed Body Program
(405) 271-2424, ext. 46282 or ext. 0
Resources
National Resources
AARP
(866) 295-7277
OK Chapter (405) 632-1945
www.aarp.org/endoflife
Alzheimer’s Association
(800) 272-3900
www.alz.org
OK Chapter www.alz.org/alzokar
Alzheimer’s Resource Room
www.aoa.gov/alz/index.asp
American Cancer Society
(800) 227-2345
OKC Office (405) 843-9888
Tulsa Office (918) 743-6767
www.cancer.org
Center for Practical Bioethics
(800) 344-3829
www.practicalbioethics.org
Last Acts
(877) 843-7953
www.lastacts.org
Medicare
www.medicare.gov
National Association of Homecare and
Hospice Agency Locator
www.nahc.org/agencylocator.html
National Hospice and Palliative Care
Organization
(800) 658-8898
www.nhpco.org
On Our Own Terms: Moyers on Dying
www.pbs.org/wnet/onourownterms
Partnership for Caring
(800) 658-8898
www.partnershipforcaring.org
Centers for Medicare and Medicaid
Services
www.cms.hhs.gov
Eldercare Locator
1-800-677-1116
www.eldercare.gov
Growth House
(415) 863-3045
www.growthhouse.org
19
Key Terms
Advance Directive for Health Care: A written document that enables you to state
what kinds of life-sustaining treatment
you wish to receive or forego if you become able to make your own decisions.
Airway Intubation: Insertion of a tube
through the wind pipe to get oxygen into
a patient’s lungs.
Cardiac Arrest: Absence of an effective
heartbeat.
Cardiopulmonary Resuscitation (CPR):
Efforts to restore breathing and heartbeat
to a patient in cardiac or respiratory arrest.
Defibrillation: Stimulation of the heart with
high voltage electrical shock.
Dialysis: Removal of waste products, salts
and extra liquid from blood by artificial
means when the kidneys fail.
Do Not Resuscitate (DNR) Order: A physician’s order not to perform CPR on a
patient.
Guardian: A person appointed by a court and
given power to make some or all decisions about the care of another person,
called the Ward, and/or the Ward’s property.
Hospice: Care provided to terminally ill patients and their families by an interdisciplinary team, working in conjunction with
a physician, aimed at relieving the physical, emotional and spiritual distress that is
often part of the dying process. Hospice
care may be delivered in the home, in
nursing facilities, in hospitals or in hospice care centers.
20
Mechanical Ventilation: Use of an artificial
breathing machine (respirator).
Palliative Care: Compassionate care that
provides medical, emotional, psychological and spiritual support. The goal
of palliative care is to meet the needs of
patients by ensuring effective pain control
and managing the symptoms that cause
discomfort.
Persistent Vegetative State: A deep and permanent unconsciousness. Patients may
have open eyes, but they have very little
brain activity and are capable only of
involuntary and reflex movements. Oklahoma’s Advance Directive form describes
this state as “persistently unconscious.”
Persistent Unconsciousness: see Persistent
Vegetative State.
Prognosis: Prediction of the probable outcome of a disease or medical condition.
Respiratory Arrest: Inability to breathe on
one’s own.
Terminal Condition: An incurable condition
from which a person will die within six
months, even if treatment is administered.
Tube Feeding: A method of artificially delivering liquid and nutrients for patients that
cannot eat or drink by mouth. Usually,
for short-term tube feeding, a tube (called
a nasogastric or “NG” tube) is inserted
through the patient’s nose and esophagus
into the stomach. For long-term feeding,
a tube may be inserted directly through
the skin into the stomach (called a gastric or “PEG” tube) or into the intestines
(called a jejunal or “J” tube).
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) 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 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.
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
_____ 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
_____ blood/fluids
_____ brain
_____ pancreas
_____ arteries
_____ bones/marrow
_____ kidneys
_____ liver
_____ tissue
_____ skin
_____ heart
_____ 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,
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 ___.
____________________________________________
Signature
____________________________________________
City of
____________________________________________
County, Oklahoma
____________________________________________
Date of birth (Optional for identification purposes)
The advance directive was signed in my presence.
_______________________________________
Signature of Witness
_______________________________________
Signature of Witness
____________________________________, OK
Residence
____________________________________, OK
Residence
Other Publications Available from the Senior Law Resource Center
Who Decides? Caring for Patients with Diminished Capacity
Oklahoma Grandparents’ Legal Guide
Published in Partnership By:
Oklahoma Attorney General’s Task Force To Improve End-of-Life Care in Oklahoma
Oklahoma Palliative Care Resource Center
Senior Law Resource Center
St. John Health System
This Project Was Initially Funded By:
The American Bar Association’s Partnership in Law and Aging Program, a project of the
Borchard Foundation Center on Law and Aging and the American Bar
Association Commission on Law and Aging
Additional Funding Was Provided By:
Hospice Foundation of Oklahoma Affiliated Fund, Inc.
Senior Law Resource Center
Copies of this guide and other Senior Law Resource Center publications may be ordered from:
Senior Law Resource Center
P.O. Box 1408
Oklahoma City, OK 73101
(405) 528-0858
FAX (405) 601-2134
[email protected]
Senior Law Resource Center publications can also be downloaded from www.senior-law.org.

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