Oklahoma § 63-3131.5 - Consent form

§ 63-3131.5. Consent form

A. For persons under the care of a health care agency, a donot-resuscitate order shall, if issued, be in accordance with the

policies and procedures of the health care agency as long as not in

conflict with the provisions of the Oklahoma Do-Not-Resuscitate Act.

B. The do-not-resuscitate consent form shall be in

substantially the following form:

FRONT PAGE

OKLAHOMA DO-NOT-RESUSCITATE (DNR) CONSENT FORM

I, _________________________, request limited health care as

described in this document. If my heart stops beating or if I stop

breathing, no medical procedure to restore breathing or heart

function will be instituted by any health care provider including,

but not limited to, emergency medical services (EMS) personnel.

I understand that this decision will not prevent me from

receiving other health care such as the Heimlich maneuver or oxygen

and other comfort care measures.

I understand that I may revoke this consent at any time in one

of the following ways:

1. If I am under the care of a health care agency, by making an

oral, written, or other act of communication to a physician or other

health care provider of a health care agency;

2. If I am not under the care of a health care agency, by

destroying my do-not-resuscitate form, removing all do-not-

Oklahoma Statutes - Title 63. Public Health and Safety

resuscitate identification from my person, and notifying my

attending physician of the revocation;

3. If I am incapacitated and under the care of a health care

agency, my representative may revoke the do-not-resuscitate consent

by written notification to a physician or other health care provider

of the health care agency or by oral notification to my attending

physician; or

4. If I am incapacitated and not under the care of a health

care agency, my representative may revoke the do-not-resuscitate

consent by destroying the do-not-resuscitate form, removing all donot-resuscitate identification from my person, and notifying my

attending physician of the revocation.

I give permission for this information to be given to EMS

personnel, doctors, nurses, and other health care providers. I

hereby state that I am making an informed decision and agree to a

do-not-resuscitate order.

____________________ OR ________________________________

Signature of Person

Signature of Representative

(Limited to an attorney-in-fact for

health care decisions acting under the

Oklahoma Health Care Agent Act, a

health care proxy acting under the

Oklahoma Advance Directive Act or a

guardian of the person appointed under

the Oklahoma Guardianship and

Conservatorship Act.)

This DNR consent form was signed in my

presence.

______________

______________________ _____________

Date

Signature of Witness

Address

______________________ _____________

Signature of Witness

Address

BACK OF PAGE

CERTIFICATION OF PHYSICIAN

(This form is to be used by an attending physician only to

certify that an incapacitated person without a representative would

not have consented to the administration of cardiopulmonary

resuscitation in the event of cardiac or respiratory arrest. An

attending physician of an incapacitated person without a

representative must know by clear and convincing evidence that the

incapacitated person, when competent, decided on the basis of

information sufficient to constitute informed consent that such

person would not have consented to the administration of

cardiopulmonary resuscitation in the event of cardiac or respiratory

arrest. Clear and convincing evidence for this purpose shall

include oral, written, or other acts of communication between the

patient, when competent, and family members, health care providers,

Oklahoma Statutes - Title 63. Public Health and Safety

or others close to the patient with knowledge of the patient's

desires.)

I hereby certify, based on clear and convincing evidence

presented to me, that I believe that ___________________________

Name of Incapacitated Person

would not have consented to the administration of cardiopulmonary

resuscitation in the event of cardiac or respiratory arrest.

Therefore, in the event of cardiac or respiratory arrest, no chest

compressions, artificial ventilation, intubations, defibrillation,

or emergency cardiac medications are to be initiated.

__________________________

_____________________________

Physician's Signature/Date

Physician's Name (PRINT)

________________________________________________________________

Physician's Address/Phone

C. Witnesses must be individuals who are eighteen (18) years of

age or older who are not legatees, devisees or heirs at law.

D. It is the intention of the Legislature that the preferred,

but not required, do-not-resuscitate form in Oklahoma shall be the

form set out in subsection B of this section.

Added by Laws 1997, c. 327, § 5, eff. Nov. 1, 1997. Amended by Laws

2010, c. 139, § 1, eff. Nov. 1, 2010; Laws 2022, c. 136, § 19,

emerg. eff. April 29, 2022.