Thursday, August 26, 2010

Center for Practical Bioethics Conference Celebrates PSDA 20 Years Later

"At the Epicenter:  Cruzan and PSCA 20 years Later"
Conference hosted by the Center for Practical Bioethics, November 12 and 13, 2010.
For registration information go to practicalbioethics.org

Tuesday, November 24, 2009

Celebrities "choose" to die at home.

On July 27, 2003, Bob Hope died at his home in Toluca Lake at 9:28 p.m. According to one of Hope's daughters, when asked on his deathbed where he wanted to be buried, he told his wife, "Surprise me."

Charlton Heston dies at home, with his wife at his side, April 5, 2008.

Walter Chronkite, longtime news anchor, died at his New York home on July 18, 2009.

Senator Edward Kennedy died in his home August 25, 2009.

Patrick Swayze dies at his ranch, with his wife at his side, September 14, 2009.

Soupy Sales died in hospice care October 22, 2009.

Paul Newman's wish was to die at home, October, 2009.


Sunday, October 25, 2009

Palliative Care is Patient-Centered Care

"When I think about palliative care, I think about it as really good, patient-centered care," says Dr. Karin Porter-Williamson, medical director for palliative care at the University of Kansas Medical Center. "It's really not inherently different from what you'd describe as excellent patient care. It is paying particular attention to all the issues, and pulling away from a disease focus to a person focus." more . . .


Seniors teach medical students elder care.
A School of Medicine and the Division of Gerontology, Geriatrics and Palliative Care for several years and recently received a jolt with a $2 million grant from the Donald W. Reynolds Foundation and a $1 million match from the university to support senior mentor programs.  http://main.uab.edu/Sites/reporter/articles/71646/

Friday, October 23, 2009

"No Country for Sick Men," Newsweek, 9/21/2009

"The fundamental truth about health care in every country," notes Princeton professor Uwe Reinhardt, one of the world's preeminent health-care economists, "is that national values, national character, determine how each system works." more . . .

Sunday, October 11, 2009



Countries:
IndiaRomaniaSouth AfricaUgandaBelizeU.S.A.
Topics:
Health
Languages:
English
With hot button issues such as swine flu, abortion and health care reform often dominating the headlines, it can be easy to overlook an equally vital, though less attention-grabbing, health issue: palliative care. This type of care focuses on relieving suffering and improving the quality of life for people facing life-threatening illnesses, such as cancer and HIV/AIDS.
World Hospice and Palliative Care Day, which takes place today, seeks to change that by celebrating and supporting hospice and palliative care globally. While it's true that one day is not enough to create real change for the millions of people who rely on or need this type of care, it can help bring much-needed attention to the issue. Not only are these stories largely omitted from news headlines, one study finds that even online educational materials about the topic need to be revised to make them more understandable. Throughout much of the world there's a lack of understanding about this type of care, as well as a lack of access to these services.
The theme for this year's World Hospice and Palliative Care Day is “Discovering your voice,” so organizers asked people from around the world to make their voices heard and submit their stories online. In response, people from countries ranging from Portugal and Indiato Malaysia reflected on the issue. Beatriz Thompson, for example, of Belize shares this account:
“This is the story of a brave little boy. His name is Julian Wohler. At the age of one and a half year he was diagnosed with neuroblastoma. Julian fought this cancer for 4 1/2 years. He underwent 5 surgeries cycles of chemo and radiation in Merida Yucatan, Mexico. Julian had to travel 11 hours from Belize to go receive treatment every 2 weeks. When the tumor came back for the last time Julian told his parents he was not going back for anymore chemo or surgery. He wanted to stay home and enjoy himself.”

Hospice Casa Sperantei in Romania
Hospice Casa Sperantei in Romania
Hospice Casa Sperantei, based in Brasov, Romania, is a leader of palliative care in Eastern Europe. The hospice received a Rising Voicesmicrogrant last year to train its staff to use new media to share and preserve their patients' stories, as well as spread awareness about Romania's palliative care issues. The project's blog shares patients' stories in Romanian. For example, Gabriel, R.G. on the blog, has leukemia and has been at the hospice since 2006. In this post, the 64-year-old discusses his difficulties in dealing with a recent setback, saying:

“My disease began last year with partial paralysis. I did 10 sessions at the hospital and I felt like everything was changing for the good. Three days later, I was in the kitchen and I fell down. Since then no more stability and I am very weakened. Firstly it affected me in a psychological way, like I was being destroyed. I was on the verge of disappearing, I wanted anything to happen, just to escape, because it is torture, a very hard torture.”
Judi Chamberlin, blogging in the United States on Life as a Hospice Patient, also shares the ups and downs of having a life-limiting illness. She suffers from a chronic lung disease and lung infection, among other health problems. In this recent post, she talks about feeling discouraged and reflects on her father:
“I find myself saying so many of the things my Dad used to say in his final months–he used to talk about feeling weary, and now I know just what he meant. Everything, even the most mundane activity, like going to the bathroom, becomes a major production. When someone would point out some nice upcoming activity he would say “hallelujah” or “whoop-de-doo,” hating to be diverted with something that felt so minor in the grand scheme of things. And although he was eighty four when he died, and I'm not quite sixty five (my birthday is October 30th), I know just what he meant when he would say, “I've lived too long.” I always planned to live to a ripe old age, but that was only if it was an active, busy life–the life I used to lead, the life I loved.”
In addition to firsthand accounts of living with a disease, many palliative care-related blogs, videos and other new media also share the views of caregivers, health care professionals and family members of someone with a life-threatening disease. In Uganda, patratm, a doctor and hematologist, tweets about various palliative care issues. In South Africa, a video shares the story of Zodwa Sithole over images of hospice care. Sithole watched her sister die of cancer at a hospice and is now part of the Hospice Palliative Care Association of South Africa.
Risa Denenberg, blogging on risa's pieces in the United States, is a nurse who looks after patients with life-threatening illnesses. In her blog she reflects on her experiences as a palliative care provider. In this post, she talks about the pain of losing a patient:
“Pager bleats its rising and lowering notes (de-da-do-da-de). Familiar as my name, but as I am wading from sleep to wake…It's the nursing home, telling me he has died. It's 2:15 am…
…The hardness was that he didn't want to die, wasn't ready, much too young, much too much undone, had just started over, this thing caught him in the neck and strangled him without so much as a warning punch. And the pain. Was terrible. Even on the highest doses of opioids I have ever prescribed. Pain mixed with fear, anger, angst. I think I loved him for these few weeks, a helpless sort of love because I couldn't make it better. I thought.
Daughter said to me: “He liked you. Really liked you. That's a big complement, you know. He sees right through shit, and you were real to him.”
shantanu.dutta, blogging on Mutiny in India, talks about a friend who died of cancer at a hospice. At the time, there seemed to be only one hospice in New Delhi, where space opened up when a patient passed away. He says he learned the value of hospice firsthand through that experience:
“The famous psycho-oncologist Buckman…said that “there was one missing chapter in Harrison's Textbook of Internal Medicine. The missing chapter was, ‘What do you do when all the treatment advised in all the other chapters fail?'
Palliative care is that missing chapter. It is missing in our planning, priorities and programs but is fast emerging from the shadows as an urgent necessity as we and our loved ones live longer and become more and more prone to debilitating and life threatening diseases that can not be perhaps be cured but with some a professional approach endured, and possibly endure well.”
October 11, 2009


Because of the overwhelming response to "Ask the Professor", this resource will be extended for a year, until the 2010 World Hospice and Palliative Care Day event sponsored by the Oklahoma Palliative Care Resource Center.  This was the only event sponsored in Oklahoma and the inquiries demonstrated a need for more education for consumers and health providers.


Address your inquiries to ok-palliative@ouhsc.edu 




The Oklahoma Palliative Care Resources Blog celebrates "World Hospice & Palliative Care Day" with "Ask the Professor".  Annette Prince, J.D., Clinical Assistant Professor at the Oklahoma University Health Sciences Center Department of Family Medicine, will address questions and comments regarding Oklahoma laws relating to planning  for medical treatment in advance of incapacity.  Address comments to email:  ok-palliative@ouhsc.edu.

This discussion does not take the place of consultation with an attorney regarding unique circumstances in an individual situation or case.
The following was one of many inquiries and concerns expressed by participants in the "Ask the Professor" event for Oklahomans on World Hospice and Palliative Care Day yesterday.



Date:
Saturday, October 10, 2009 12:36 PM

To:
catcher9@cox.net Add to Addresses

Subject:
Question

Size:
3 KB
My husband has ALS and is on a respirator. We want to turn it off according to his living will but his doctor thinks it is immoral and doesn't agree? What are our rights about this?


The Professor's answer:  


Oklahoma law requires physicians to follow advance directives (living wills).


If his doctor refuses to follow your husband's wishes, he is required to 
facilitate his referral to a physician who will follow his directions. 
 

If you have questions email:
 ok-palliative@ouhsc.edu

Sunday, October 4, 2009

World Hospice and Palliative Care Day, October 10

World Hospice and Palliative Care Day is October 10, when people take part in events and activities to raise awareness and funds for the development of palliative care. This year’s theme is “Discover your voice”, based on the idea that anyone can speak out and support palliative care. Anyone can make a difference. more at http://www.worldday.org/ .


You can donate to the Oklahoma Palliative Care Resource Center at:


http://www.fammed.ouhsc.edu/Palliative-Care/donations.htm



Planning for end-of-life care can let patients decide


She sat in her hospital bed surrounded by the palliative-care team and her relatives as the meeting drew to a close. Clinical ethicist Clint Moore III leaned forward.
"What have we missed?" he said. "Have we had every question answered?"
There was still the matter of the two Yorkie dogs that Hayes' sister worried would bark at in-home caregivers. "I think that can be figured out," Moore said. "Agencies have dealt with that before."
Hayes thanked the palliative-care team, shook Preodor's hand and was ready to follow her chosen plan: to stop taking all but comfort-care medications, have her pain controlled and go home.   more . . .

Monday, September 28, 2009

Rocket Science in Health Care is "Delivery"

Bill Moyers, on his PBS television show, interviewed Dr. Jim Yong Kim, a physician and anthropologist, who is the new president of Dartmouth. A global health leader, Dr. Kim is co-founder of the humanitarian group, Partners in Health, and earlier in his career was a senior official with the World Health Organization, and the chair of three different departments at Harvard University. Asked what's wrong with our health care system, Dr. Kim responded, in part, "My own particular take on it is that I think for many, many years, we've been working under the fantasy that if we come up with new drugs and new treatments, we're done. The rest of the system will take care of itself. In my view, the rocket science in health and health care is how we deliver it. And unfortunately, there's not a single medical school that I know of that actually teaches the delivery of health care as one of the essential sciences...So my own view of it is that we have to rethink fundamentally the kind of research we do and the kind of people we educate, so that they'll think about the complexity of delivery as a topic that we can take on and study and learn about as a science."  more . . .


http://www.pbs.org/moyers/journal/09112009/transcript2.html

ON END-OF-LIFE ISSUES

Collecting data on palliative care in hospitals for list of best hospitals to die in and other options for terminally ill patients.  more . . .
ttp://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/09/27/EDUP19RGAH.DTL

Sunday, September 27, 2009

Joan Teno to Receive NHPCO Distinguished Researcher Award


The Distinguished Researcher Award recognizes an outstanding body of research that has contributed to the advancement of hospice and palliative care.
Dr. Teno is being honored for her exceptional ongoing commitment and extraordinary contribution to understanding how to measure and improve the quality of end-of-life care for vulnerable populations. Both a researcher and a clinician, Dr. Teno is well recognized for her research focusing on medical care for dying persons and frail persons residing in nursing homes.
She created the Brown University Family Evaluation of Hospice Care, a post-death survey tool that collects information from family caregivers about a loved one's hospice experience. Hundreds of hospice programs across the country participate in FEHC through NHPCO and valuable data is provided to the field.  more . . .
http://www.prnewswire.com/news-releases/1400-professionals-gather-in-denver-to-focus-on-clinical-care-at-the-end-of-life-61116817.html

Witnesses for Advance Directives, Durable Powers of Attorney, etc.

I visited a hospital in OKC today to witness a document for a patient to provide for health care in the event that she cannot speak for herself in the future.  I asked a nurse to act as the second witness and was informed that it was against the law for health providers to witness documents in the hospital.  Of course, it was to no avail to try to convince the nurse that wasn't true.  So, I went an email to the hospital "patient services" department.

Hopefully, this will encourage the hospital to change their  policy.  If I could not have found a visitor to sign, the patient would not have been able to execute a document that would allow her wishes for health care to be known and honored.

Thursday, September 17, 2009

Oklahoma Advance Directive Act, 2006

The amended Oklahoma Advance Directive Act became effective May 17, 2006, but many Oklahomans and health providers have not completed the new form. The new act includes a new advance directive living will which allows individuals to plan in advance for any health condition which leaves them unable to make their own medical decisions. The new law also allows the health care proxy to make all medical decisions for a patient who is unable to make those decisions for themselves.  These options were not possible under the former law.


The new law does not invalidate any advance directives executed prior to May, 2006, but Oklahomans are encouraged to take advantage of the new form which allows more freedom to plan for medical treatment near the end of life.


The new legislation and the new form can be viewed and downloaded on the Oklahoma Palliative Care Resource Center website, located in the OUHSC College of Medicine, Department of Family & Preventive Medicine at
http://www.fammed.ouhsc.edu/Palliative-Care/ .

For our readers’ convenience, the full texts of the Oklahoma Hydration and Nutrition for Incompetent Patients Act and the Oklahoma Advance Directive Act, as amended by the Oklahoma Legislature, 2006, are provided below.

Among the important changes are:

(1) a revised Advance Directive Form which allows for unlimited refusal of medical treatment by a qualified patient, and

(2) expanded authority to allow an appointed health care proxy to make medical decisions for a patient determined to be unable to make decisions regarding medical treatment.

Oklahomans can now plan in advance of a time when they are incapable of making informed decisions regarding health care. The form allows specific directions to health providers in the event of a terminal illness, a state of persistent unconciousness, an end-stage condition, or other conditions in which decisions regarding life-sustaining treatment and artificially administered nutrition and hydration are appropriate. The form can include directions regarding whether the individual wishes to receive or refuse CPR, dialysis, or other mechanical interventions in specific circumstances.

The form includes a section for appointment of a health care proxy who is authorized to make all medical treatment decisions for patients who are unable to make decisions for themselves including decisions regarding life-sustaining treatments and artificially administered nutrition and hydration. The proxy is limited in regard to life-sustaining treatment or artificially administered nutrition and hydration by the specific directions included in the form by the individual. The proxy can still execute a Do-Not-Resusitate form for the patient.

The amended act also allows a woman to make decisions for her treatment in the event of inability to make informed decisions during a course of pregnancy.

The legislature also amended the statutory presumption that an individual wishes to receive artificially administered hydration or nutrition. The presumption shall not apply if the attending physician of the incompetent patient knows that the patient, when competent, decided based upon informed consent that such treatment should be withheld or withdrawn.

Any valid advance directive executed prior to the amendments remains valid.

Hydration and Nutrition for Incompetent Patients Act as Amended 2006

Title 63 O.S. Section3080.1 - Short Title

Sections 1 through 5 of this act shall be known and may be cited as the "Hydration and Nutrition for Incompetent Patients Act".

Title 63 O.S. Section3080.2 - Definitions

As used in the Hydration and Nutrition for Incompetent Patients Act:

1. "Attending physician" means the physician who has primary responsibility for the overall medical treatment and care of a patient;

2. "Final stage" means the last stage of a terminal illness or injury in which, even with the use of medical treatment, the person with the terminal illness or injury is in the dying process and will die within a reasonably short period of time;

3. "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinary course of business or practice of a profession;

4. "Incompetent patient" means any person who:

a. is a minor, or

b. has been declared legally incompetent to make decisions affecting medical treatment or care, or

c. in the reasonable judgment of the attending physician, is unable to make decisions affecting medical treatment or other health care services;

5. "Nutrition" means sustenance administered by way of the gastrointestinal tract;

6. "Physician" means a physician or surgeon licensed by the State Board of Medical Examiners or State Board of Osteopathy; and

7. "Terminal illness or injury" means an incurable and irreversible medical condition that, even with the use of medical treatment, will result in the death of a person from that condition or a complication arising from that condition.

Title 63 O.S. Section 3080.3 Presumption for Artificially Administered Hydration and Nutrition

It shall be presumed that every incompetent patient has directed his health care providers to provide him with hydration and nutrition to a degree that is sufficient to sustain life.

Title 63 O.S. Section 3080.4 Inapplicability of Presumption

A. The presumption pursuant to Section 3080.3 of this title shall not apply if:

1. The attending physician of the incompetent patient knows that the patient, when competent, decided on the basis of information sufficient to constitute informed consent that artificially administered hydration or artificially administered nutrition should be withheld or withdrawn from him;

2. A court finds by clear and convincing evidence that the patient, when competent, decided on the basis of information sufficient to constitute informed consent that artificially administered hydration or artificially administered nutrition should be withheld or withdrawn from him;

3. An advance directive has been executed pursuant to the Oklahoma Natural Death Act specifically authorizing the withholding or withdrawal of nutrition and/or hydration;

4. An advance directive has been executed pursuant to the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act specifically authorizing the withholding or withdrawal of nutrition and/or hydration;



5. An advance directive for health care has been executed pursuant to the Oklahoma Advance Directive Act specifically authorizing the withholding or withdrawal of nutrition and/or hydration;



6. In the reasonable medical judgment of the incompetent patient's attending physician and a second consulting physician, artificially administered hydration or artificially administered nutrition will itself cause severe, intractable, and long-lasting pain to the incompetent patient or such nutrition or hydration is not medically possible; or



7. In the reasonable medical judgment of the incompetent patient's attending physician and a second consulting physician:



a. the incompetent patient is chronically and irreversibly incompetent,



b. the incompetent patient is in the final stage of a terminal illness or injury, and



c. the death of the incompetent patient is imminent.



B. No advance directive shall be deemed to satisfy the provisions of subsection A of this section unless the advance directive complies with the requirements of Section 3101.4 or Section 3101.14 of this title.



C. Hydration or nutrition may not be withheld or withdrawn pursuant to paragraph 7 of subsection A of this section if this would result in death from dehydration or starvation rather than from the underlying terminal illness or injury.



Title 63 O.S. Section3080.5 - Withdrawal of Medical Treatment, Care, Nutrition or Hydration from Incompetent Patients.





A. Notwithstanding any other provision of law, no person and no health care facility shall be required to participate in or provide facilities for medical treatment or care of an incompetent patient who is to die as the result of dehydration or starvation.



B. The law of this state shall not be construed to permit withdrawal or withholding of medical treatment, care, nutrition or hydration from an incompetent patient because of the mental disability or mental status of that patient.



C. No guardian, public or private agency, court, or any other person shall have the authority to make a decision on behalf of an incompetent patient to withhold or withdraw hydration or nutrition from said patient except in the circumstances and under the conditions specifically provided for in Section 3080.4 of this title.





Oklahoma Advance Directive Act as Amended, 2006

63 O.S. Section 3101.1 Title of Act

Sections 3101.1 through 3101.16 of this title shall be known and may be cited as the "Oklahoma Advance Directive Act".

63 O.S. Section 3101.2 Purpose



The purpose of the Oklahoma Advance Directive Act is to:



1. Recognize the right of individuals to control some aspects of their own medical care and treatment, including but not limited to the right to decline medical treatment or to direct that it be withdrawn, even if death ensues;



2. Recognize that the right of individuals to control some aspects of their own medical treatment is protected by the Constitution of the United States and overrides any obligation the physician and other health care providers may have to render care or to preserve life and health;



3. Recognize that decisions concerning one's medical treatment involve highly sensitive, personal issues that do not belong in court, even if the individual is incapacitated, so long as a proxy decision-maker can make the necessary decisions based on the known intentions, personal views, or best interests of the individual. If evidence of the individual's wishes is sufficient, those wishes should control; if there is not sufficient evidence of the individual's wishes, the proxy's decisions should be based on the proxy's reasonable judgment about the individual's values and what the individual's wishes would be based upon those values. The proper role of the court is to settle disputes and to act as the proxy decision-maker of last resort when no other proxy is authorized by the individual or is otherwise authorized by law;



4. Restate and clarify the law to ensure that the individual's advance directive for health care will continue to be honored during incapacity without court involvement; and



5. Encourage and support health care instructions by the individual in advance of incapacity and the delegation of decision-making powers to a health care proxy.



B. To be sure that the individual's health care instructions and proxy decision-making will be effective, the Oklahoma Advance Directive Act also includes necessary and appropriate protection for proxies and health care providers who rely in good faith on the instructions of the individual and the decisions of an authorized proxy.



C. The Oklahoma Advance Directive Act does not condone, authorize, or approve mercy killing, assisted suicide, or euthanasia.



63 O.S. Section 3101.3 Definitions



As used in the Oklahoma Advance Directive Act:



1. "Advance directive for health care" means any writing executed in accordance with the requirements of Section 3101.4 of this title and may include a living will, the appointment of a health care proxy, or both such living will and appointment of a proxy;



2. "Attending physician" means the physician who has primary responsibility for the treatment and care of the patient;



3. "Declarant" means any individual who has issued an advance directive according to the procedure provided for in Section 3101.4 of this title;



4. "End-stage condition" means a condition caused by injury, disease, or illness, which results in severe and permanent deterioration indicated by incompetency and complete physical dependency for which, to a reasonable degree of medical certainty, treatment of the irreversible condition would be medically ineffective;



5. "Health care provider" means a person who is licensed, certified, or otherwise authorized by the law of this state to administer health care in the ordinary course of business or practice of a profession;



6. "Health care proxy" is an individual eighteen (18) years old or older appointed by the declarant as attorney-in-fact to make health care decisions including, but not limited to, the provision, withholding, or withdrawal of life-sustaining treatment if a qualified patient, in the opinion of the attending physician and another physician, is persistently unconscious, incompetent, or otherwise mentally or physically incapable of communication;



7. "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;



8. "Person" means an individual, corporation, business trust, estate, trust, partnership, association, joint venture, government, governmental subdivision or agency, or any other legal or commercial entity;



9. "Physician" means an individual licensed to practice medicine in this state;



10. "Qualified patient" means a patient eighteen (18) years of age or older who has executed an advance directive and who has been determined to be incapable of making an informed decision regarding health care, including the provision, withholding, or withdrawal of life-sustaining treatment, by the attending physician and another physician who have examined the patient;



11. "State" means a state, territory, or possession of the United States, the District of Columbia, or the Commonwealth of Puerto Rico; and



12. "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.



63 O.S. Section 3101.4 Advance Directive Form and Procedures



A. An individual of sound mind and eighteen (18) years of age or older may execute at any time an advance directive for health care governing the provision, withholding, or withdrawal of life-sustaining treatment. The advance directive shall be signed by the declarant and witnessed by two individuals who are eighteen (18) years of age or older who are not legatees, devisees, or heirs at law.



B. An advance directive that is not in the form set forth in subsection C of this section and that is executed in Oklahoma shall not be deemed to authorize the withholding or withdrawal of artificially administered nutrition and/or hydration unless it specifically authorizes the withholding or withdrawal of artificially administered nutrition and/or hydration in the declarant’s own words or by a separate section, separate paragraph, or other separate subdivision that deals only with nutrition and/or hydration and which section, paragraph, or other subdivision is separately initialed, separately signed, or otherwise separately marked by the declarant.



C. An advance directive may be in substantially the following form:



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 medical treatment, 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:





_____ 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.



Initial only

one option

_____ 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.



_____

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

(Initial if applicable)





(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:





_____ 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.



Initial only

one option

_____ 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.



_____

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

(Initial if applicable)





(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:





_____ 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.



Initial only

one option

_____ 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.



_____

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

(Initial if applicable)





(4) OTHER. Here you may:



(a) describe other conditions in which you would want life-sustaining treatment or artificially administered nutrition and hydration provided, withheld, or withdrawn,



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



(c) do both of these:



_____________________________________________________________________________



_____________________________________________________________________________



_____________________________________________________________________________



_____________________________________________________________________________



_____________________________________________________________________________



_____________________________________________________________________________



_______

Initial



II. My Appointment of My Health Care Proxy



If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers pursuant to the Oklahoma Advance Directive Act to follow the instructions of _______________, whom I appoint as my health care proxy. If my health care proxy is unable or unwilling to serve, I appoint ______________ as my alternate health care proxy with the same authority. My health care proxy is authorized to make whatever medical treatment decisions I could make if I were able, except that 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 therapy



_____ advancement of medical science, research, or education



_____ advancement of dental science, research, or education



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



_____

My entire body




or

_____

The following body organs or parts:

_____

lungs

_____

liver





_____

pancreas

_____

heart





_____

kidneys

_____

brain





_____

skin

_____

bones/marrow





_____

blood/fluids

_____

tissue





_____

arteries

_____

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)

This advance directive was signed in my presence.



___________________________________

Witness

___________________________, Oklahoma

Residence

___________________________________

Witness

___________________________, Oklahoma

Residence

D. A physician or other health care provider who is furnished the original or a photocopy of the advance directive shall make it a part of the declarant's medical record and, if unwilling to comply with the advance directive, promptly so advise the declarant.



E. In the case of a qualified patient, the patient's health care proxy, in consultation with the attending physician, shall have the authority to make treatment decisions for the patient including the provision, withholding, or withdrawal of life-sustaining procedures if so indicated in the patient's advance directive.



F. A person executing an advance directive appointing a health care proxy who may not have an attending physician for reasons based on established religious beliefs or tenets may designate an individual other than the designated health care proxy, in lieu of an attending physician and other physician, to determine the lack of decisional capacity of the person. Such designation shall be specified and included as part of the advance directive executed pursuant to the provisions of this section.



63 O.S. Section 3101.5 When Advance Directive Becomes Operative



A. An advance directive becomes operative when:



1. It is communicated to the attending physician; and



2. The declarant is no longer able to make decisions regarding administration of life-sustaining treatment. When the advance directive becomes operative, the attending physician and other health care providers shall act in accordance with its provisions or comply with the provisions of Section 9 of this act.



B. In the event more than one valid advance directive has been executed and not revoked, the last advance directive so executed shall be construed to be the last wishes of the declarant and shall become operative pursuant to subsection A of this section.



63 O.S. Section 3101.6 When Advance Directive Becomes Operative



A. An advance directive may be revoked in whole or in part at any time and in any manner by the declarant, without regard to the declarant's mental or physical condition. A revocation is effective upon communication to the attending physician or other health care provider by the declarant or a witness to the revocation.



B. The attending physician or other health care provider shall make the revocation a part of the declarant's medical record.



63 O.S. Section 3101.7 Qualified Patient-Determination-Record



The determination of the attending physician and another physician that the patient is a qualified patient shall become a part of the patient's medical record.



63 O.S. Section 3101.8 Right to Make Life-Sustaining Treatment Decisions - Alleviation of Pain - Pregnant Patient





A. A patient may make decisions regarding life-sustaining treatment as long as the patient is able to do so.



B. Even if life-sustaining treatment or artificial administration of nutrition and hydration are withheld or withdrawn, the patient shall be provided with medication or other medical treatment to alleviate pain and will be provided with oral consumption of food and water.



C. If a qualified patient has been diagnosed as pregnant and that diagnosis is known to the attending physician, the pregnant patient shall be provided with life-sustaining treatment and artificially administered hydration and nutrition, unless the patient has specifically authorized, in her own words, that during a course of pregnancy, life-sustaining treatment and/or artificially administered hydration and/or nutrition shall be withheld or withdrawn. If it is not known if the patient is pregnant, the said physician shall, where appropriate considering age and other relevant factors, determine whether or not the patient is pregnant.



Title 63 O.S. Section3101.9 - Duty of Health Care Provider Who is Unwilling to Comply with Act





An attending physician or other health care provider who is unwilling to comply with the Oklahoma Advance Directive Act shall as promptly as practicable take all reasonable steps to arrange care of the declarant by another physician or health care provider when the declarant becomes a qualified patient. Once a patient has established a physician-patient relationship with a physician or a provider-patient relationship with another health care provider, if the physician or other health care provider refuses to comply with a medical treatment decision made by or on behalf of the patient pursuant to the Oklahoma Advance Directive Act, or with a medical treatment decision made by such a patient who has decision-making capacity, and if the refusal would in reasonable medical judgment be likely to result in the death of the patient, then the physician or other health care provider must comply with the medical treatment decision pending the completion of the transfer of the patient to a physician or health care provider willing to comply with the decision. Nothing in this section shall require the provision of treatment if the physician or other health care provider is physically or legally unable to provide or is physically or legally unable to provide without thereby denying the same treatment to another patient. Nothing in this section may be construed to alter any legal obligation or lack of legal obligation of a physician or other health care provider to provide medical treatment, nutrition, or hydration to a patient who refuses or is unable to pay for them.



Title 63 O. S. Section3101.10 - Nonliability - Health Care Provider, Health Care Proxy, and Others





A. In the absence of knowledge of the revocation of an advance directive, a person is not subject to civil or criminal liability or discipline for unprofessional conduct for carrying out the advance directive pursuant to the requirements of the Oklahoma Advance Directive Act.



B. A physician or other health care provider, whose actions under the Oklahoma Advance Directive Act are in accord with reasonable medical standards, is not subject to criminal or civil liability or discipline for unprofessional conduct with respect to those actions; provided, that this subsection may not be construed to authorize a violation of Section 3101.9 of this title. In making decisions and determinations pursuant to the Oklahoma Advance Directive Act the physician shall use 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.



C. An individual designated as a health care proxy, pursuant to Section 3101.4 of this title, to make health care decisions for a declarant and whose decisions regarding the declarant are made in good faith pursuant to the Oklahoma Advance Directive Act, is not subject to criminal or civil liability, or discipline for unprofessional conduct with respect to those decisions.



Title 63 O.S. Section3101.11 - Sanctions and Penalties for Certain Acts





A. A physician or other health care provider who willfully fails to arrange the care of a patient in accordance with Section 3101.9 of this title shall be guilty of unprofessional conduct.



B. A physician who willfully fails to record the determination of the patient's condition in accordance with Section 3101.7 of this title shall be guilty of unprofessional conduct.



C. Any person who willfully conceals, cancels, defaces, alters, or obliterates the advance directive of another without the declarant's consent, or who falsifies or forges a revocation of the advance directive of another shall be, upon conviction, guilty of a felony.



D. A person who in any way falsifies or forges the advance directive of another, or who willfully conceals or withholds personal knowledge of a revocation as provided in Section 3101.6 of this title shall be, upon conviction, guilty of a felony.



E. A person who requires or prohibits the execution of an advance directive as a condition for being insured for, or receiving, health care services shall be, upon conviction, guilty of a felony.



F. A person who coerces or fraudulently induces another to execute an advance directive or revocation shall be, upon conviction, guilty of a felony.



G. The sanctions provided in this section do not displace any sanction applicable under other law.



Title 63 O.S. Section3101.12 - Interpretation and Effect of Act





A. Death resulting from the withholding or withdrawal of life-sustaining treatment in accordance with the Oklahoma Advance Directive Act shall not constitute, for any purpose, a suicide or homicide.



B. The making of an advance directive pursuant to Section 3101.4 of this title shall not affect in any manner the sale, procurement, or issuance of any policy of life insurance or annuity, nor shall it affect, impair, or modify the terms of an existing policy of life insurance or annuity. A policy of life insurance or annuity shall not be legally impaired or invalidated in any manner by the withholding or withdrawal of life-sustaining treatment from an insured qualified patient, regardless of any term of the policy or annuity to the contrary.



C. A person shall not prohibit or require the execution of an advance directive as a condition for being insured for, or receiving, health care services.



D. The Oklahoma Advance Directive Act creates no presumption concerning the intention of an individual who has revoked or has not executed an advance directive with respect to the use, withholding, or withdrawal of life-sustaining treatment.



E. The Oklahoma Advance Directive Act shall not affect the right of a patient to make decisions regarding use of life-sustaining treatment, so long as the patient is able to do so, or impair or supersede any right or responsibility that a person has to effect the withholding or withdrawal of medical care; provided, that this subsection may not be construed to authorize a violation of Section 3101.9 of this title.



F. The Oklahoma Advance Directive Act shall not be construed to condone, authorize, or approve mercy killing, assisted suicide, or euthanasia.



G. Failure to designate a health care proxy in accordance with Section 3101.4 of this title shall not be interpreted to invalidate the authority of a health care proxy to make life-sustaining treatment decisions if otherwise authorized by law.



Title 63 O.S. Section3101.13 - Presumption - Compliance With Act - Validity of Directive





In the absence of knowledge to the contrary, a physician or other health care provider may presume that an advance directive complies with the Oklahoma Advance Directive Act and is valid.



Title 63 O.S. Section3101.14 - Validity of Document Executed in Another State





Execution of an advance directive by an individual, which provides for the provision, withholding, or withdrawal of life-sustaining treatment for that individual or for the appointment of another to give directions to provide, withhold, or withdraw life-sustaining treatment, executed in another state in compliance with the law of that state or of this state is valid for purposes of the Oklahoma Advance Directive Act to the extent the advance directive does not exceed authorizations allowed under the laws of this state; provided, that no such advance directive shall be deemed to authorize the withholding or withdrawal of artificially administered nutrition and/or hydration unless it specifically authorizes such withholding or withdrawal of artificially administered nutrition and/or hydration, and either the advance directive:



1. Was executed by a person who was not a resident of Oklahoma at the time of execution; or



2. Specifically authorizes the withholding or withdrawal of artificially administered nutrition and/or hydration in the declarant’s own words or by a separate section, separate paragraph, or other separate subdivision that deals only with nutrition and/or hydration and which section, paragraph, or other subdivision is separately initialed, separately signed, or otherwise separately marked by the person executing the advance directive.



Title 63 O.S. Section3101.15 - Directives Executed Under Prior Acts





A. Any directive to a physician executed pursuant to the former Oklahoma Natural Death Act, 63 O.S. 1991, Section 3101 et seq., which was executed prior to September 1, 1992, shall be enforceable according to its terms until revoked and shall have the same force and effect as if made pursuant to this act. Such directive shall be binding on the attending physician whether or not the person who executed the directive was in a terminal condition at the time of execution unless there is evidence that the person executing the directive intended that it should be binding only if executed or re-executed after the person became afflicted with a terminal condition as defined by the former Oklahoma Natural Death Act.



B. Any advance directive executed prior to the enactment of any amendment to the Oklahoma Advance Directive Act which substantially complied with the law in effect at the time of the execution of the directive shall be enforceable according to its terms until revoked and shall have the same force and effect as if made pursuant to this act, as amended.

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