{"data":{"id":"us-ok/okla.-stat.-tit.-63-63-3105.4","jurisdiction":"us-ok","citation":"Okla. Stat. tit. 63, § 63-3105.4","heading":"Format and content of form","body":"1. At the top of the first page of the standardized format\n\nOklahoma physician orders for life-sustaining treatment form the\n\nfollowing wording in all capitals shall appear against a contrasting\n\ncolor background: \"FORM SHALL ACCOMPANY PERSON WHEN TRANSFERRED OR\n\nDISCHARGED\"; at the bottom of the first page the following wording\n\nin all capitals shall appear against a contrasting color background:\n\n\"HIPAA PERMITS DISCLOSURE TO HEALTH CARE PROFESSIONALS AND PROXY\n\nDECISION MAKERS AS NECESSARY FOR TREATMENT\".\n\n2. There shall be an introductory section, the left block of\n\nwhich shall contain the name \"Oklahoma Physician Orders for Life-\n\nSustaining Treatment (POLST)\" followed by the words, \"This Physician\n\nOrder set is based on the patient's current medical condition and\n\nwishes and is to be reviewed for potential replacement in the case\n\nof a substantial change in either, as well as in other cases listed\n\nunder F. Any section not completed indicates full treatment for\n\nthat section. Photocopy or fax copy of this form is legal and\n\nvalid.\" and the right block of which shall contain lines for the\n\npatient's name, the patient's date of birth and the effective date\n\nof the form followed by the statement, \"Form must be reviewed at\n\nleast annually.\"\n\n3. In Section A of the form, the left block shall contain, in\n\nbold font, \"A. Check One\", and the right block shall be headed, in\n\nbold font, \"Cardiopulmonary Resuscitation (CPR): Person has no\n\npulse and is not breathing.\" below which there shall be a checkbox\n\nfollowed by \"Attempt Resuscitation (CPR)\", then a checkbox followed\n\nby \"Do Not Attempt Resuscitation (DNR/ no CPR)\", and below which\n\nshall be the words, \"When not in cardiopulmonary arrest, follow\n\norders in B, C and D below.\"\n\n4. In Section B of the form, the left block shall contain, in\n\nbold, \"B. Check One\", and the right block shall be headed, in bold,\n\n\"Medical Interventions: Person has pulse and/or is breathing.\"\n\nBelow this there shall be a checkbox followed by, in bold, \"Full\n\nTreatment\" followed by, \"Includes the use of intubation, advanced\n\nairway interventions, mechanical ventilation, defibrillation or\n\ncardio version as indicated, medical treatment, intravenous fluids,\n\nand cardiac monitor as indicated. Transfer to hospital if\n\nindicated. Include intensive care. Includes treatment listed under\n\n\"Limited Interventions\" and \"Comfort Measures\", followed by, in\n\nbold, \"Treatment Goal: Attempt to preserve life by all medically\n\neffective means.\"\n\nBelow this there shall be a checkbox followed by, in bold,\n\n\"Limited Interventions\" followed by, \"Includes the use of medical\n\ntreatment, oral and intravenous medications, intravenous fluids,\n\ncardiac monitoring as indicated, noninvasive bi-level positive\n\nairway pressure, a bag valve mask or other advanced airway\n\ninterventions. Includes treatment listed under \"Comfort Measures\",\n\nfollowed by, \"Do not use intubation or mechanical ventilation.\n\nTransfer to hospital if indicated. Avoid intensive care.\" followed\n\nby, in bold, \"Treatment Goal: Attempt to preserve life by basic\n\nmedical treatments.\"\n\nBelow this there shall be a checkbox followed by, in bold,\n\n\"Comfort Measures only\" followed by, \"Includes keeping the patient\n\nclean, warm and dry; use of medication by any route; positioning,\n\nwound care and other measures to relieve pain and suffering. Use\n\noxygen, suction and manual treatment of airway obstruction as needed\n\nfor comfort. Transfer from current location to intermediate\n\nfacility only if needed and adequate to meet comfort needs and to\n\nhospital only if comfort needs cannot otherwise be met in the\n\npatient's current location (e.g., hip fracture; if intravenous route\n\nof comfort measures is required).\"\n\nBelow this there shall be, in italics, \"Additional Orders:\"\n\nfollowed by an underlined space for other instructions.\n\n5. In Section C of the form, the left block shall contain, in\nf needed and adequate to meet comfort needs and to\n\nhospital only if comfort needs cannot otherwise be met in the\n\npatient's current location (e.g., hip fracture; if intravenous route\n\nof comfort measures is required).\"\n\nBelow this there shall be, in italics, \"Additional Orders:\"\n\nfollowed by an underlined space for other instructions.\n\n5. In Section C of the form, the left block shall contain, in\n\nbold, \"C. Check One\" and the right block shall be headed, in bold,\n\n\"Antibiotics\".\n\nBelow this there shall be a checkbox followed by, in bold, \"Use\n\nantibiotics to preserve life.\"\n\nBelow this there shall be a checkbox followed by, in bold,\n\n\"Trial period of antibiotics if and when infection occurs.\" After\n\nthis there shall be, in italics, \"*Include goals below in E.\"\n\nBelow this there shall be a checkbox followed by, in bold,\n\n\"Initially, use antibiotics only to relieve pain and discomfort.\"\n\nAfter this there shall be, in italics, \"+Contact patient or\n\npatient's representative for further direction.\"\n\nBelow this there shall be, in italics, \"Additional Orders:\"\n\nfollowed by an underlined space for other instructions.\n\n6. In Section D of the form, the left block shall contain, in\n\nbold, \"D. Check One in Each Column\", and the right block shall be\n\nheaded in bold, \"Assisted Nutrition and Hydration\", below which\n\nshall be \"Administer oral fluids and nutrition, if necessary by\n\nspoon feeding, if physically possible.\" Below these the right block\n\nshall be divided into three columns.\n\nThe leftmost column shall be headed, \"TPN (Total Parenteral\n\nNutrition-provision of nutrition into blood vessels).\" Below this\n\nthere shall be a checkbox followed by, in bold, \"TPN long-term\"\n\nfollowed by \"if needed\". Below this there shall be a checkbox\n\nfollowed by, in bold, \"TPN for a trial period*\". Below this there\n\nshall be a checkbox followed by, in bold, \"Initially, no TPN+\".\n\nThe middle column shall be headed \"Tube Feeding\". Below this\n\nthere shall be a checkbox followed by, in bold, \"Long-term feeding\n\ntube\" followed by \"if needed\". Below this there shall be a checkbox\n\nfollowed by, in bold, \"Feeding tube for a trial period*\". Below\n\nthis there shall be a checkbox followed by, in bold, \"Initially, no\n\nfeeding tube\".\n\nThe rightmost column shall be headed, \"Intravenous (IV) Fluids\n\nfor Hydration\". Below this there shall be a checkbox followed by,\n\nin bold, \"Long-term IV fluids\" followed by \"if needed\". Below this\n\nthere shall be a checkbox followed by, in bold, \"IV fluids for a\n\ntrial period*\". Below this there shall be a checkbox followed by,\n\nin bold, \"Initially, no IV fluids+\".\n\nRunning below all the columns there shall be, in italics,\n\n\"Additional Orders:\" followed by an underlined space for other\n\ninstructions, followed by, in italics, \"*Include goals below in E.\n\n+Contact patient or patient's representative for further direction.\"\n\n7. In Section E of the form, the left block shall contain, in\n\nbold, \"E. Check all that apply\" and the right block shall be\n\nheaded, in bold, \"Patient Preferences as a Basis for this POLST\n\nForm\" shall include the following:\n\na. below the heading there shall be a box including the\n\nwords, in bold, \"Patient Goals/Medical Condition:\"\n\nfollowed by an adequate space for such information,\n\nb. below this there shall be a checkbox followed by, \"The\n\npatient has an advance directive for health care in\n\naccordance with Sections 3101.4 or 3101.14 of Title 63\n\nof the Oklahoma Statutes.\" Below that there shall be\n\na checkbox followed by, \"The patient has a durable\n\npower of attorney for health care decisions in\n\naccordance with the Oklahoma Health Care Agent Act.\"\n\nBelow that shall be the indented words, \"Date of\n\nexecution\" followed by an underlined space. Below\n\nthat shall be the words, \"If POLST not being executed\n\nby patient: We certify that this POLST is in\n\naccordance with the patient's advance directive.\"\n\nBelow this there shall be an underlined space\npower of attorney for health care decisions in\n\naccordance with the Oklahoma Health Care Agent Act.\"\n\nBelow that shall be the indented words, \"Date of\n\nexecution\" followed by an underlined space. Below\n\nthat shall be the words, \"If POLST not being executed\n\nby patient: We certify that this POLST is in\n\naccordance with the patient's advance directive.\"\n\nBelow this there shall be an underlined space\n\nunderneath which shall be positioned the words, \"Name\n\nand Position (print) Signature\" and \"Signature of\n\nPhysician\",\n\nc. below these shall be the words, \"Directions given by:\"\n\nand below that a checkbox followed by \"Patient\", a\n\ncheckbox followed by \"Minor's custodial parent or\n\nguardian\", a checkbox followed by \"Attorney-in-fact\",\n\na checkbox followed by \"Health care proxy\", and a\n\ncheckbox followed by \"Other legally authorized\n\nperson:\" followed by an underlined space. Beneath or\n\nbeside the checkbox and \"Other legally authorized\n\nperson:\" and the underlined space shall be the words\n\n\"Basis of Authority:\" followed by an underlined space,\n\nand\n\nd. below these shall be a four-column table with four\n\nrows. In the top row the first column shall be blank;\n\nthe second column shall have the words, \"Printed\n\nName\"; the third column shall have the word,\n\n\"Signature\", and the fourth column shall have the\n\nword, \"Date\". In the remaining rows the second\n\nthrough fourth columns shall be blank. In the first\n\ncolumn of these rows, in the second row shall be the\n\nwords, \"Attending physician\"; in the third row shall\n\nbe the words, \"Patient or other individual checked\n\nabove (patient's representative)\"; and in the fourth\n\nrow shall be the words, \"Health care professional\n\npreparing form (besides doctor).\"\n\n8. Section F of the form, which shall have the heading, in\n\nbold, \"Information for Patient or Representative of Patient Named on\n\nthis Form\", shall include the following language, appearing in bold\n\non the form:\n\n\"The POLST form is always voluntary and is usually for persons\n\nwith advanced illness. Before providing information for or signing\n\nit, carefully read \"Information for Patients and Their Families -\n\nYour Medical Treatment Rights Under Oklahoma Law\", which the health\n\ncare provider must give you. It is especially important to read the\n\nsections on CPR and food and fluids, which have summaries of\n\nOklahoma laws that may control the directions you may give. POLST\n\nrecords your wishes for medical treatment in your current state of\n\nhealth. Once initial medical treatment is begun and the risks and\n\nbenefits of further therapy are clear, your treatment wishes may\n\nchange. Your medical care and this form can be changed to reflect\n\nyour new wishes at any time. However, no form can address all the\n\nmedical treatment decisions that may need to be made. An advance\n\nhealth care directive is recommended, regardless of your health\n\nstatus. An advance directive allows you to document in detail your\n\nfuture health care instructions and/or name a health care agent to\n\nspeak for you if you are unable to speak for yourself.\n\nThe State of Oklahoma affirms that the lives of all are of equal\n\ndignity regardless of age or disability and emphasizes that no one\n\nshould ever feel pressured to agree to forego life-preserving\n\nmedical treatment because of age, disability or fear of being\n\nregarded as a burden.\n\nIf this form is for a minor for whom you are authorized to make\n\nhealth care decisions, you may not direct denial of medical\n\ntreatment in a manner that would violate the child abuse and neglect\n\nlaws of Oklahoma. In particular, you may not direct the withholding\n\nof medically indicated treatment from a disabled infant with life-\n\nthreatening conditions, as those terms are defined in 42 U.S.C.,\n\nSection 5106g or regulations implementing it and 42 U.S.C., Section\n\n5106a.\"\nmanner that would violate the child abuse and neglect\n\nlaws of Oklahoma. In particular, you may not direct the withholding\n\nof medically indicated treatment from a disabled infant with life-\n\nthreatening conditions, as those terms are defined in 42 U.S.C.,\n\nSection 5106g or regulations implementing it and 42 U.S.C., Section\n\n5106a.\"\n\n9. Section G of the form, which shall have the heading, in\n\nbold, \"Directions for Completing and Implementing Form\", shall\n\ninclude the following three subdivisions:\n\na. the first subdivision, entitled \"COMPLETING POLST\",\n\nshall have the following language with the words, \"The\n\nsignature of the patient or the patient's\n\nrepresentative is required\" appearing in bold on the\n\nform:\n\n\"POLST must be reviewed and prepared in consultation\n\nwith the patient or the patient's representative after\n\nthat person has been given a copy of \"Information for\n\nPatients and Their Families - Your Medical Treatment\n\nRights Under Oklahoma Law\". POLST must be reviewed\n\nand signed by a physician to be valid. Be sure to\n\ndocument the basis for concluding the patient had or\n\nlacked capacity at the time of execution of the form\n\nin the patient's medical record. If the patient lacks\n\ncapacity, any current advance directive form must be\n\nreviewed and the patient's representative and\n\nphysician must both certify that POLST complies with\n\nit. The signature of the patient or the patient's\n\nrepresentative is required; however, if the patient's\n\nrepresentative is not reasonably available to sign the\n\noriginal form, a copy of the completed form with the\n\nsignature of the patient's representative must be\n\nplaced in the medical record as soon as practicable\n\nand \"on file\" must be written on the appropriate\n\nsignature line on this form.\",\n\nb. the second subdivision, entitled \"IMPLEMENTING POLST\",\n\nshall have the following language:\n\n\"If a minor protests a directive to deny the minor\n\nlife-preserving medical treatment, the denial of\n\ntreatment may not be implemented pending issuance of a\n\njudicial order resolving the conflict. A health care\n\nprovider unwilling to comply with POLST must comply\n\nwith the transfer and treatment pending transfer\n\nrequirements of Section 3101.9 of Title 63 of the\n\nOklahoma Statutes as well as those of the\n\nNondiscrimination in Treatment Act, Sections 3090.2\n\nand 3090.3 of Title 63 of the Oklahoma Statutes\", and\n\nc. the third subdivision, entitled \"REVIEWING POLST\",\n\nshall have the following language:\n\n\"This POLST must be reviewed at least annually or\n\nearlier if:\n\nThe patient is admitted to or discharged from a\n\nmedical care facility; there is substantial change in\n\nthe patient's health status; or the treatment\n\npreferences of the patient or patient's representative\n\nchange.\"\n\nThe same requirements for participation of the patient or\n\npatient's representative, and signature by both a physician and the\n\npatient or the patient's representative, that are described under\n\n\"COMPLETING POLST\" shall also apply when POLST is reviewed, and must\n\nbe documented in Section I.\n\n10. Section H of the form, which shall have the heading, in\n\nbold, \"REVOCATION OF POLST\", shall have the following language, with\n\nthe words specified below appearing in bold on the form:\n\n\"If POLST is revised or becomes invalid, write in bold the word\n\n\"VOID\" in large letters on the front of the form. After voiding the\n\nform a new form may be completed. A patient with capacity or the\n\nindividual or individuals authorized to sign on behalf of the\n\npatient in Section E of this form may void this form. If no new\n\nform is completed, full treatment and resuscitation is to be\n\nprovided, except as otherwise authorized by Oklahoma law.\"\n\n11. Section I of the form, which shall have the heading, in","path":["OK Code","Title 63"],"source_url":"https://www.oklegislature.gov/OK_Statutes/CompleteTitles/os63.pdf","current_through":"2026-08-14","vintage":"open-us-law v2026.08, retrieved 2026-09-14","retrieved_at":"2026-09-14T18:32:36Z","sha256":"4973122c4121a14499a097f34fb23b2490235650657ec1f67d4982ceec7c26ec","source_id":"us-ok","stale":false,"prev":"us-ok/okla.-stat.-tit.-63-63-3105.3","next":"us-ok/okla.-stat.-tit.-63-63-3105.5"},"notice":"GroundRules: Original legal text. Not legal advice."}