Advance Directive

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. Statement of Belief

Catholics believe that life is a gift of a loving God. I believe that life is a holy gift for which we are responsible but do not own. I believe that assisted death and suicide destroy human life and are never allowed. As an adult, I have the right to make decisions about my health care and medical treatment that might unnecessarily prolong the dying process beyond the limits dictated by reason and good judgment. As a Catholic, I may never choose to end my own life.

I direct that those caring for me avoid doing anything that is contrary to the moral teachings of the Catholic Church. If I fall terminally ill, I ask that I be told of this so that I might prepare myself for death, and I ask that efforts be made that I be attended by a Catholic priest and receive the Sacramental Pastoral Care.

II. Living Will

a. If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers, pursuant to the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act, to withhold or withdraw treatment from me under the circumstances I have indicated below by my initials. I understand that I will be given treatment that is necessary for my comfort or to alleviate my pain.

b. If I have a terminal condition or am persistently unconscious:

(1) I direct that life-sustaining treatment shall be withheld or withdrawn if such treatment would only prolong my process of dying, and if my attending physician and another physician determine that I:

(a) have an incurable and irreversible condition that even with the administration of life-sustaining treatment will cause my death within six (6) months:

(Circle one only) Yes No

(b) or, am in an irreversible condition in which thought and awareness of self and environment are absent:

(Circle one only) Yes No

(2) I understand that the subject of the artificial administration of nutrition and hydration (food and water) that will only prolong the process of dying from an incurable and irreversible condition or for individuals who have become persistently unconscious is of particular importance. I understand that if I do not initial the “yes” boxes below, artificially administered nutrition and hydration will be administered to me. I further understand that if I initial the “yes” boxes below, I am authorizing the withholding or withdrawal of artificially administer nutrition (food) and hydration (water):

(a) if I have an incurable and irreversible condition that even with the administration of life-sustaining treatment will cause my death within six (6) months,

(Circle one only) Yes No

(b) or, if I am an irreversible condition in which thought and awareness of self and environment are absent.

(Circle one only) Yes No

(3) I direct that (add other medical directives if any):

Examples:

I want those making decisions on my behalf to avoid doing anything that intends and directly causes my death by deed or omission. Medical treatments may be forgone or withdrawn if they do not offer a reasonable hope of benefit to me or if they entail excessive burdens, or impose excessive expense on my family or the community. There should be a presumption in favor of providing me with nutrition and hydration, assuming of course they are of benefit to me. In accord with the teachings of my Church, I have no moral objection to the use of medication or procedures necessary for my comfort even if they may indirectly and unintentionally shorten my life.

I believe that food (nutrition) and fluids (hydration) are not medical treatments, nor medical procedures, but ordinary means of preserving life. Therefore, I direct my health care provider(s) to provide me with food and fluids orally, intravenously, by tube, or by other means to the full extent necessary both to preserve my life and to assure me the optimal health possible. Furthermore, if at such time I am unable to eat and drink on my own (i.e. in a natural manner) food and fluids must be provided to me in an assisted manner (i.e. by tubes or similar manner) unless (a) my death is imminent (i.e. likely to happen without delay); or (b) I am unable to assimilate food or fluids; or (c) food or fluids endanger my condition.

(Circle one only) Yes No

III. My Appointment of My Health Care Proxy

If my attending physician and another physician determine that I am no longer able to make decisions regarding my medical treatment, I direct my attending physician and other health care providers pursuant to the Oklahoma Rights of the Terminally Ill or Persistently Unconscious Act to follow the instructions of ญญญญญ__________________________ 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 can be made by my health care proxy or alternate health care proxy only as I indicate in the foregoing sections.

(Circle one only) Yes No

IV. Anatomical Gifts

I direct that at the time of my death my entire body or designated body organs or body parts be donated for purposes of transplantation, therapy, advancement of medical or dental science or research or education pursuant to the provisions of the Uniform Anatomical Gift Act. Death means either irreversible cessation of circulatory and respiratory functions or irreversible cessation of all functions of the entire brain, including the brain stem. I specifically donate:

NO I do not agree to donate my body or organs.

YES My entire body.

YES The following body organs or part checked below:

(____) lungs (____) liver (____) pancreas

(____) heart (____) kidneys (____) brain

(____) skin (____) bones/marrow (____) bloods/fluids,

(____) tissue (____) arteries (____) eyes/cornea/lens

V. General Provision

a. I understand that if I have been diagnosed as pregnant and that diagnosis is known to my attending physician, this advance directive shall have no force or effect during the course of my pregnancy.

b. In the absence of my ability to give directions regarding the use of life-sustaining procedures, it is my intention that this advance directive shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment including, but not limited to, the administration of any life-sustaining procedures, and I accept the consequences of such refusal.

c. This advance directive shall be in effect until it is revoked.

d. I understand that I may revoke this advance directive at any time.

e. I understand and agree that if I have any prior directives, and if I sign this advance directive, my prior directives are revoked.

f. I understand the full importance of this advance directive and I am emotionally and mentally competent to make this advance directive.

Signed this__ day of , 2006.

____________________________________
(Print Name)

____________________________________
(Signature)

_______________________________________

______________, County of ________, Oklahoma
(City)

_____________________________________
(Date of Birth)

This advance directive was signed in my presence.

____________________________________ ___________________________________
Witness name (please type or print) Signature of Witness

_____________________________________ ____________________________________
Address of Witness Date

_____________________________________ ____________________________________
Witness name (please type or print) Signature of Witness

______________________________________ ____________________________________
Address of Witness Date

NOTE: Witnesses must be over 18 and should not be anyone who will take under your will or otherwise might inherit from you