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Health Care Directive

Appointment of Health Care Proxy


Appointment of Health Care Proxy

Who are you appointing as your Health Care Proxy?
In other words, who would you like to make health care decisions for you should you become unable to do so yourself?

Health Care Proxy

e.g. Jamie Taylor Lee

Oklahoma


e.g. 202 Pine Avenue

e.g. Oklahoma City



e.g. Spouse, Brother, Friend, etc.






Frequently Asked Questions
Who can act as my Health Care Proxy?Anyone over the age of majority and of sound mind can act as your Health Care Proxy. Spouses and close family members are common choices.Will this information be kept private?Yes. LawDepot® is committed to protecting your privacy and ensuring that your visit to our website is completely secure. For more information, see our Privacy Policy.


Your Health Care Directive

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Advance Directive for Health Care of _________________________

Definitions
For the purposes of this document, the following definitions apply:

"Terminal condition" means 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.

"Persistently Unconscious" means an irreversible condition, as determined by the attending physician and another physician, in which thought and awareness of self and environment are absent.

"Life-sustaining Treatment" means any medical procedure or intervention, including but not limited to the artificial administration of nutrition and hydration if the declarant has specifically authorized the withholding and withdrawal of artificially administered nutrition and hydration, that, when administered to a qualified patient, will serve only to prolong the process of dying or to maintain the patient in a condition of persistent unconsciousness. The term "life-sustaining treatment" shall not include the administration of medication or the performance of any medical treatment deemed necessary to alleviate pain nor the normal consumption of food and water.

"Artificially supplied nutrition and hydration" (or artificially administered food and water) means the provision of nutrients or fluids by a tube inserted in vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).

"Comfort care" means treatment, including prescription medication, provided to a patient for the sole purpose of alleviating pain, and does not include artificially administered food and water.

Declaration
I, _________________________, being of sound mind and eighteen (18) years of age or older, willfully and voluntarily make known my desire, by my instructions to others through my living will, or by my appointment of a health care proxy, or both, that my life shall not be artificially prolonged under the circumstances set forth below. I thus do hereby declare:

I. Living Will

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 provide, withhold or withdraw treatment from me under the circumstances:

  1. If I am in a terminal condition:

    I direct that life-sustaining treatment shall be given to me as necessary.

    I understand that the artificial administration of nutrition and hydration (food and water) that will only prolong the process of dying from an incurable and irreversible condition is a particularly important subject. I understand that if I do not specifically state otherwise, artificially administered nutrition and hydration may be administered to me. If I can no longer chew or swallow by myself or with someone helping me, I direct that nutrition and hydration be administered to me artificially unless, in the opinion of my attending physician, the artificial administration of nutrition and hydration would be harmful to me.

    I understand that the provision of comfort care that will prolong the process of dying from an incurable and irreversible condition is a particularly important subject when such care will prolong the dying process. I understand that comfort care will be provided to me. I direct that comfort care be provided to me unless, in the opinion of my attending physician, the provision of comfort care would be harmful to me.

  2. If I am persistently unconscious:

    I direct that life-sustaining treatment shall be given to me as necessary.

    I understand that the artificial administration of nutrition and hydration (food and water) for individuals who have become persistently unconscious is a particularly important subject. I understand that if I do not specifically state otherwise, artificially administered nutrition and hydration will be administered to me if I am persistently unconscious. If I can no longer chew or swallow by myself or with someone helping me, I direct that nutrition and hydration be administered to me artificially unless, in the opinion of my attending physician, the artificial administration of nutrition and hydration would be harmful to me.

    I understand that the provision of comfort care that will prolong the process of dying from an incurable and irreversible condition is a particularly important subject. I understand that comfort care will be provided to me. I direct that comfort care be provided to me unless, in the opinion of my attending physician, the provision of comfort care would be harmful to me.

  3. Other Directives:

    In the absence of my ability to make health care decisions for myself, I intend that these directives be honored by my family and physicians as the final expression of my constitutional right to direct my own health care.

    I do not wish to add further directives.

II. My Appointment of My Health Care Proxy

  1. 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 my _______________________, _______________________, of _______________________, _______________________ in the State of Oklahoma, whom I appoint as my health care proxy. _______________________ may be contacted at ______________________________.
  2. Authority of Health Care Proxy

    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 the following sections.

    In accordance with the Health Insurance Portability and Accountability Act of 1996, 42 USC 1320d ("HIPAA"), I authorize my health care proxy to review and receive any information regarding my physical or mental health, including medical and hospital records.

    If I have a terminal condition:

    1. I authorize my health care proxy to direct that life-sustaining treatment 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.

      Signature: ______________________________

    2. I understand that the artificial administration of nutrition and hydration (food and water) is a particularly important subject. I understand that if I do not specifically state otherwise, artificially administered nutrition and hydration will be administered to me when I can no longer chew or swallow by myself.  If I can no longer chew or swallow by myself or with someone helping me, I direct that artificially provided nutrition and hydration be withheld or withdrawn from me. I understand that by signing this paragraph, I am authorizing my health care proxy to direct that artificially administered nutrition (food) and hydration (water) be withheld or withdrawn under the circumstances described above.

      Signature: ______________________________

    3. I understand that the provision of comfort care that will prolong the process of dying from an incurable and irreversible condition is a particularly important subject. I understand that Oklahoma law does not allow me to direct that comfort care be withheld.  However, I ask that my wishes regarding the provision of comfort care be followed regardless of whether they may go beyond what Oklahoma law allows.  I ask that my right to direct my own health care as guaranteed by the U.S. Constitution be followed and given precedence in this matter, and I authorize my health care proxy to direct that comfort care be withheld or withdrawn from me if it would prolong my dying.

      Signature: ______________________________

    If I am persistently unconscious:

    1. I authorize my health care proxy to direct that life-sustaining treatment 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.

      Signature: _______________________________________

    2. I understand that the artificial administration of nutrition and hydration (food and water) for individuals who have become persistently unconscious is a particularly important subject. I understand that if I do not specifically state otherwise, artificially administered nutrition and hydration will be administered to me when I can no longer chew or swallow by myself. I authorize my health care proxy to direct that artificially provided nutrition and hydration be withheld or withdrawn from me if I can no longer chew or swallow by myself or with someone helping me.  I understand that by signing this paragraph, I am authorizing my health care proxy to direct that artificially administered nutrition (food) and hydration (water) be withheld or withdrawn under the circumstances described above.

      Signature: ______________________________

    3. I understand that the provision of comfort care that will prolong the process of dying from an incurable and irreversible condition is a particularly important subject. I understand that Oklahoma law does not allow me to direct that comfort care be withheld.  However, I ask that my wishes regarding the provision of comfort care be followed regardless of whether they may go beyond what Oklahoma law allows.  I ask that my right to direct my own health care as guaranteed by the U.S. Constitution be followed and given precedence in this matter, and I authorize my  health care proxy to direct that comfort care be withheld or withdrawn from me if it would prolong my dying.
The remainder of this document will be available when you have purchased a license.


When creating a document, LawDepot’s template gives you the following options:

  • Only specify your health care preferences
  • Only appoint someone to make medical decisions for you
  • Specify your health care preferences and appoint someone to make medical decisions for you

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