Oklahoma Statutes Title 63 Section 3103
DIRECTIVE TO PHYSICIANS
Directive made this _________________ day of ___________.
I _______________, being of sound mind and twenty-one years of age or older, willfully and voluntarily make known my desire that my life shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:
1. If at any time I should have an incurable irreversible condition caused by injury, disease, or illness certified to be a terminal condition by two physicians, I direct that life-sustaining procedures be withheld or withdrawn and that I be permitted to die naturally, if the application of life-sustaining procedures would serve only to artificially prolong the moment of my death and where my physician determines that my death is imminent whether or not life-sustaining procedures are utilized;
2. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this directive shall be honored by my family and physician(s) as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal;
3. If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or effect during the course of my pregnancy;
4. I have been diagnosed and notified as having a terminal condition by ______________, M.D. or D.O. whose address is ________________, I understand that if I have not filed in the name and address of the physician, it shall be presumed that I did not have a terminal condition when I made out this directive;
5. This directive shall be in effect until revoked;
6. I understand the full import of this directive and I am emotionally and mentally competent to make this directive; and
7. I understand that I may revoke this directive at any time.
The Declarant has been personally known to me and I believe him or her to be of sound mind. I am twenty-one (21) years of age or older, I am not related to the Declarant by blood or marriage, nor would I be entitled to any portion of the estate of the Declarant upon the death of the Declarant, nor am I the attending physician or directly financially responsible for Declarant’s medical care, or any person who has a claim against any portion of the estate of the Declarant upon the death of the Declarant.
State of Oklahoma
County of ____________________
Before me, the undersigned authority, on this day personally appeared _____________________ Declarant, _____________________ witness and ________________________________ witness whose names are subscribed to the foregoing instrument in their respective capacities, and, all of said persons being by me duly sworn, the Declarant declared to me and to the said witnesses in my presence that said instrument is his or her “Directive to Physicians”, and that the Declarant had willingly and voluntarily made and executed it as the free act and deed of the Declarant for the purposes therein expressed.
The foregoing instrument was acknowledged before me this __________________ day of ______________________, 20__________.
Notary Public in and for ____________ County, Oklahoma
My Commission Expires:
Oklahoma Statutes Title 63 Section 3103
This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Oklahoma. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.
- Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.
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