Medical Directive - DNR

OREGON ADVANCE DIRECTIVE FOR HEALTH CARE, DO NOT RESUSCITATE ORDER, AND RELATED DOCUMENTS

Prepared Under ORS Chapter 127 -- Powers of Attorney; Advance Directives for Health Care; POLST; Declarations for Mental Health Treatment

IMPORTANT NOTICE: This document package includes an Oregon Advance Directive for Health Care, a Do Not Resuscitate (DNR) section, guidance on Portable Orders for Life-Sustaining Treatment (POLST), appointment of a Health Care Representative, instructions for health care, a Declaration for Mental Health Treatment, and organ donation preferences. Oregon law provides specific requirements for the execution, witnessing, and revocation of advance directives. Read all instructions carefully before completing this document.

TABLE OF CONTENTS

1. Overview and Purpose
2. Oregon Advance Directive for Health Care
3. Part A: Appointment of Health Care Representative
4. Part B: Instructions for Health Care
5. DNR Order Section
6. POLST Form Guidance
7. Declaration for Mental Health Treatment
8. Organ and Tissue Donation Preferences
9. Witness Requirements and Signatures
10. Provider Acknowledgment
11. Revocation Procedures
12. Filing and Distribution Instructions
13. Practice Notes with ORS Citations
14. Sources and References

1. OVERVIEW AND PURPOSE

1.1 What Is an Advance Directive?

An advance directive is a legal document that allows you to express your wishes about health care decisions in advance, in case you later become unable to make or communicate those decisions yourself. Under Oregon law (ORS 127.505 et seq.), an advance directive may include:

• Appointment of a Health Care Representative -- a person you choose to make health care decisions on your behalf if you become incapacitated
• Instructions for Health Care -- your written preferences regarding life-sustaining treatment, comfort care, tube feeding, and other medical interventions
• Any combination of the above

1.2 What Is a DNR Order?

A Do Not Resuscitate (DNR) order is a medical order directing health care providers not to perform cardiopulmonary resuscitation (CPR) if your heart stops beating or if you stop breathing. In Oregon, a DNR is most effectively implemented through a POLST form (Portable Orders for Life-Sustaining Treatment), which is a medical order signed by a physician, nurse practitioner, or physician assistant. This template includes both an advance directive DNR preference section and guidance on obtaining a POLST.

1.3 Key Distinctions Under Oregon Law

1.4 Who Should Complete This Document?

This document is appropriate for any adult (age 18 or older) who is a resident of Oregon or who receives health care in Oregon and wishes to:

☐ Appoint a trusted person to make health care decisions on their behalf
☐ Provide instructions about their preferences for life-sustaining treatment
☐ Express a preference regarding CPR and resuscitation
☐ Provide instructions for mental health treatment
☐ State organ and tissue donation preferences

2. OREGON ADVANCE DIRECTIVE FOR HEALTH CARE

(Pursuant to ORS 127.505 - 127.585)

OREGON ADVANCE DIRECTIVE FOR HEALTH CARE

I, [________________________________], being of sound mind and at least 18 years of age, make this Advance Directive for Health Care.

Date of Birth: [__/__/____]

Address: [________________________________]

City: [________________________________] State: Oregon ZIP: [____]

Phone: [________________________________]

Email: [________________________________]

I understand that this advance directive allows me to:

• Choose a person (a "health care representative") to make health care decisions for me when I am unable to make them myself; and/or
• State my wishes about health care when I am unable to speak for myself.

I understand that:

• I do not have to fill out every part of this document; I can complete only the parts I wish
• I can change or cancel this advance directive at any time
• If I appoint a health care representative, that person cannot make decisions for me unless I am incapable of making them myself
• My health care representative must follow my wishes to the extent they are known; if my wishes are unclear, my representative must act in my best interest

3. PART A: APPOINTMENT OF HEALTH CARE REPRESENTATIVE

3.1 Primary Health Care Representative

I appoint the following person as my Health Care Representative to make health care decisions for me if my attending physician or nurse practitioner determines that I am incapable of making my own health care decisions:

Name: [________________________________]

Relationship to Me: [________________________________]

Address: [________________________________]

City: [________________________________] State: [____] ZIP: [____]

Home Phone: [________________________________]

Cell Phone: [________________________________]

Work Phone: [________________________________]

Email: [________________________________]

3.2 First Alternate Health Care Representative

If my primary Health Care Representative is unable, unwilling, or unavailable to serve, I appoint the following person as my First Alternate Health Care Representative:

Name: [________________________________]

Relationship to Me: [________________________________]

Address: [________________________________]

City: [________________________________] State: [____] ZIP: [____]

Home Phone: [________________________________]

Cell Phone: [________________________________]

Work Phone: [________________________________]

Email: [________________________________]

3.3 Second Alternate Health Care Representative

If both my primary and first alternate Health Care Representative are unable, unwilling, or unavailable to serve, I appoint the following person as my Second Alternate Health Care Representative:

Name: [________________________________]

Relationship to Me: [________________________________]

Address: [________________________________]

City: [________________________________] State: [____] ZIP: [____]

Home Phone: [________________________________]

Cell Phone: [________________________________]

3.4 Authority of Health Care Representative

My Health Care Representative shall have the authority to make all health care decisions on my behalf that I could make for myself, including but not limited to (ORS 127.525):

☐ Consenting to, refusing, or withdrawing consent to any health care treatment, procedure, or service
☐ Consenting to admission to or discharge from any health care facility
☐ Reviewing my medical records and receiving medical information about my condition
☐ Hiring and discharging health care providers
☐ Making decisions about life-sustaining treatment, including withholding or withdrawing such treatment
☐ Making decisions about artificially administered nutrition and hydration (tube feeding)
☐ Making anatomical gift decisions (organ and tissue donation) consistent with my wishes stated in this directive

3.5 Limitations on Health Care Representative (If Any)

I place the following limitations or restrictions on the authority of my Health Care Representative (leave blank if no limitations):

[________________________________]

[________________________________]

[________________________________]

3.6 Special Instructions for Health Care Representative

I want my Health Care Representative to know the following about my values, beliefs, and preferences that should guide health care decisions:

[________________________________]

[________________________________]

[________________________________]

[________________________________]

4. PART B: INSTRUCTIONS FOR HEALTH CARE

4.1 Close to Death

If my attending physician or nurse practitioner determines that I am close to death and life-sustaining treatment would only postpone the moment of my death:

☐ I want life-sustaining treatment that my physician or nurse practitioner believes is appropriate.

☐ I want to receive only comfort care measures, even if that choice may hasten my death. I do NOT want life-sustaining treatment.

☐ I want my Health Care Representative to decide for me.

☐ Other instructions: [________________________________]

4.2 Permanently Unconscious

If my attending physician or nurse practitioner determines that I am permanently unconscious (i.e., in a persistent vegetative state or irreversible coma) and will not regain consciousness:

☐ I want life-sustaining treatment that my physician or nurse practitioner believes is appropriate.

☐ I want to receive only comfort care measures. I do NOT want life-sustaining treatment.

☐ I want my Health Care Representative to decide for me.

☐ Other instructions: [________________________________]

4.3 Advanced Progressive Illness

If my attending physician or nurse practitioner determines that I have an advanced, progressive illness (such as advanced dementia, advanced Parkinson's disease, or end-stage organ failure) and am no longer able to recognize family or communicate meaningfully:

☐ I want life-sustaining treatment that my physician or nurse practitioner believes is appropriate.

☐ I want to receive only comfort care measures. I do NOT want life-sustaining treatment.

☐ I want my Health Care Representative to decide for me.

☐ Other instructions: [________________________________]

4.4 Extraordinary Suffering

If my attending physician or nurse practitioner determines that I have a condition that causes me extraordinary suffering that cannot be relieved:

☐ I want life-sustaining treatment that my physician or nurse practitioner believes is appropriate.

☐ I want to receive only comfort care measures, even if that choice may hasten my death.

☐ I want my Health Care Representative to decide for me.

☐ Other instructions: [________________________________]

4.5 Artificially Administered Nutrition and Hydration (Tube Feeding)

If I am in any of the conditions described above and unable to take food or water by mouth:

☐ I want to receive tube feeding (artificially administered nutrition and hydration) for as long as medically appropriate.

☐ I do NOT want tube feeding. I understand that this may result in my death from dehydration or malnutrition.

☐ I want a trial period of tube feeding for [____] days/weeks, after which it should be discontinued if there is no improvement in my condition.

☐ I want my Health Care Representative to decide about tube feeding for me.

☐ Other instructions: [________________________________]

4.6 Comfort Care and Pain Management

Regardless of the choices above, I ALWAYS want the following comfort care measures:

☐ Adequate pain medication, even if it may hasten my death
☐ Medications to relieve anxiety, agitation, and restlessness
☐ Mouth care, skin care, and hygiene measures
☐ Turning and repositioning for comfort
☐ Warm or cool compresses as needed
☐ Emotional and spiritual support
☐ Other: [________________________________]

4.7 Specific Treatments -- Preferences

Please indicate your preferences regarding the following specific treatments:

Cardiopulmonary Resuscitation (CPR):

☐ I WANT CPR attempted if my heart stops or I stop breathing
☐ I do NOT want CPR attempted (DNR preference -- see Section 5)
☐ I want my Health Care Representative to decide

Mechanical Ventilation (Breathing Machine):

☐ I WANT mechanical ventilation if I cannot breathe on my own
☐ I do NOT want mechanical ventilation
☐ I want a trial period of [____] days/hours, after which it should be withdrawn if there is no improvement
☐ I want my Health Care Representative to decide

Dialysis:

☐ I WANT dialysis if my kidneys fail
☐ I do NOT want dialysis
☐ I want my Health Care Representative to decide

Antibiotics:

☐ I WANT antibiotics for infections
☐ I want antibiotics ONLY for comfort (to reduce fever, pain, or discomfort)
☐ I do NOT want antibiotics
☐ I want my Health Care Representative to decide

Blood Transfusions:

☐ I WANT blood transfusions if needed
☐ I do NOT want blood transfusions
☐ I want my Health Care Representative to decide

Surgery:

☐ I WANT surgery if recommended by my physicians
☐ I want surgery ONLY for comfort (e.g., to relieve an obstruction causing pain)
☐ I do NOT want surgery
☐ I want my Health Care Representative to decide

4.8 Additional Instructions

I have the following additional instructions about my health care:

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

5. DNR ORDER SECTION

5.1 Advance Directive DNR Preference

By selecting this option, I express my preference that CPR (cardiopulmonary resuscitation) NOT be performed on me. I understand that:

• This preference, stated in my advance directive, will guide my Health Care Representative and health care providers
• For this preference to be immediately honored by emergency medical services (EMS) and all health care providers, I should also obtain a POLST form with a DNR order signed by a licensed health care professional (see Section 6)
• An advance directive alone, without a POLST, may not be sufficient to prevent resuscitation in an emergency setting

☐ I DO NOT WANT CPR. If my heart stops beating or if I stop breathing, I do not want cardiopulmonary resuscitation (CPR) or any other resuscitative measures attempted. I want to be allowed to die naturally.

☐ I WANT CPR. If my heart stops beating or if I stop breathing, I want cardiopulmonary resuscitation and all other resuscitative measures attempted.

5.2 DNR Identification

If I have a POLST form with a DNR order, I understand that I may wear or carry DNR identification (such as a DNR bracelet or necklace) to alert EMS personnel of my wishes. I should ensure that:

☐ My POLST form is posted in a visible and accessible location in my home (typically on the refrigerator or near the front door)
☐ My family members and caregivers know where my POLST form is located
☐ A copy of my POLST form accompanies me to any health care facility
☐ My POLST is registered with the Oregon POLST Registry (see Section 6)

6. POLST FORM GUIDANCE

6.1 What Is a POLST?

The Portable Orders for Life-Sustaining Treatment (POLST) is a medical order form -- not merely a statement of wishes like an advance directive. A POLST:

• Is printed on a distinctive bright green form in Oregon
• Must be signed by the patient (or the patient's legally recognized health care decision maker) AND a physician, nurse practitioner, or physician assistant
• Contains medical orders regarding CPR, medical interventions (comfort measures, limited treatment, or full treatment), antibiotics, and artificially administered nutrition
• Is immediately actionable by all health care providers, including EMS
• Is governed by ORS 127.635 through ORS 127.684

6.2 Who Should Have a POLST?

A POLST is appropriate for individuals who:

☐ Have a serious, life-limiting illness
☐ Are elderly and frail
☐ Have a progressive chronic illness
☐ Want a medical order that will be honored by EMS and across health care settings
☐ Want to ensure that their CPR and life-sustaining treatment preferences are immediately honored

Note: A POLST is NOT a substitute for an advance directive. An advance directive applies broadly and appoints a decision-maker; a POLST provides specific medical orders for current conditions. Both documents should be completed for comprehensive planning.

6.3 POLST Sections

The Oregon POLST form includes the following sections:

Section A: Cardiopulmonary Resuscitation (CPR)

☐ Attempt Resuscitation / CPR
☐ Do Not Attempt Resuscitation / DNR (Allow Natural Death)

Section B: Medical Interventions

☐ Comfort Measures Only -- focus on comfort; do not transfer to hospital for life-sustaining treatment unless needed for comfort
☐ Limited Additional Interventions -- basic medical treatments including IV fluids, cardiac monitoring; avoid intensive care and intubation; transfer to hospital if indicated
☐ Full Treatment -- all available medical interventions; transfer to hospital; intensive care if indicated

Section C: Antibiotics

☐ No antibiotics; use other measures for comfort
☐ Use antibiotics only if treatment can be given orally
☐ Use antibiotics if medically indicated (route determined by health care professional)

Section D: Medically Administered Nutrition

☐ No medically administered nutrition (no feeding tube)
☐ Trial period of medically administered nutrition
☐ Long-term medically administered nutrition if indicated

6.4 How to Obtain a POLST

Step 1: Discuss your wishes with your physician, nurse practitioner, or physician assistant

Step 2: The health care professional will complete the POLST form based on your conversation and medical condition

Step 3: Both you (or your health care representative) and the health care professional sign the POLST

Step 4: The original POLST stays with you (at home, in your medical records, etc.)

Step 5: The POLST will be registered with the Oregon POLST Registry (managed by the Oregon Health Authority) unless you opt out. Registration allows health care professionals to access your POLST orders electronically.

6.5 Oregon POLST Registry

☐ The Oregon POLST Registry is an electronic database that stores POLST orders
☐ Health care providers can access the registry to verify a patient's POLST orders
☐ Registration is automatic unless the patient opts out
☐ For more information: https://oregonpolst.org
☐ Registry website: https://polst.oregonpolst.org

7. DECLARATION FOR MENTAL HEALTH TREATMENT

(Pursuant to ORS 127.700 - 127.737)

Oregon law uniquely provides for a Declaration for Mental Health Treatment, which allows individuals to state their preferences for mental health care in advance. This declaration is separate from the advance directive for general health care.

7.1 Declaration

I, [________________________________], being of sound mind and at least 18 years of age, make this Declaration for Mental Health Treatment.

I understand that this declaration will be used to make mental health treatment decisions on my behalf if I become incapable of making my own mental health treatment decisions, as determined by a qualified mental health professional.

7.2 Appointed Decision Maker for Mental Health

☐ I appoint the same Health Care Representative named in Part A of this document to also make mental health treatment decisions on my behalf.

☐ I appoint a DIFFERENT person to make mental health treatment decisions:

Name: [________________________________]

Relationship: [________________________________]

Address: [________________________________]

Phone: [________________________________]

Email: [________________________________]

7.3 Preferences for Mental Health Treatment

Medications:

☐ I consent to the following medications: [________________________________]

☐ I do NOT consent to the following medications: [________________________________]

☐ I want my decision maker to decide about medications for me, considering the preferences I have stated

Additional medication instructions:

[________________________________]

[________________________________]

Electroconvulsive Therapy (ECT):

☐ I consent to ECT if recommended by my treating psychiatrist
☐ I do NOT consent to ECT under any circumstances
☐ I want my decision maker to decide about ECT for me

Hospitalization:

☐ I consent to voluntary psychiatric hospitalization if recommended
☐ I do NOT consent to voluntary psychiatric hospitalization
☐ I want my decision maker to decide about hospitalization for me

Preferred Treatment Facilities:

☐ I prefer to receive mental health treatment at: [________________________________]

☐ I do NOT want to receive treatment at: [________________________________]

Preferred Mental Health Providers:

☐ I prefer the following mental health provider(s): [________________________________]

☐ I do NOT want to be treated by: [________________________________]

Other Mental Health Instructions:

[________________________________]

[________________________________]

[________________________________]

7.4 Duration of Mental Health Declaration

This Declaration for Mental Health Treatment is effective for [____] years from the date of execution, unless revoked sooner. Under ORS 127.709, a declaration for mental health treatment is effective for a period not to exceed 3 years from the date of execution.

8. ORGAN AND TISSUE DONATION PREFERENCES

(Pursuant to ORS 97.954 -- Oregon Revised Uniform Anatomical Gift Act)

8.1 Donation Decision

☐ I WANT to be an organ and tissue donor. Upon my death, I donate:

☐ Any needed organs and tissues
☐ Only the following organs and/or tissues: [________________________________]
☐ My body for anatomical study and research (whole body donation)

☐ I do NOT want to be an organ or tissue donor.

☐ I want my Health Care Representative or family to decide about organ and tissue donation after my death.

8.2 Donation Purpose

If I have chosen to donate, my donation is for (check all that apply):

☐ Transplantation
☐ Therapy
☐ Research
☐ Education
☐ Any medically appropriate purpose

8.3 Donation Registry

☐ I am registered with the Oregon Donor Program (Donate Life Northwest)
☐ I am NOT registered but wish to register (visit https://www.donatelifenw.org)
☐ I have indicated my donation wishes on my Oregon driver's license or ID card

8.4 Special Instructions Regarding Donation

[________________________________]

[________________________________]

9. WITNESS REQUIREMENTS AND SIGNATURES

9.1 Oregon Witness Requirements (ORS 127.515)

Under Oregon law, an advance directive must be signed and witnessed as follows:

The Principal (You) Must:
☐ Sign the advance directive in the presence of two adult witnesses; OR
☐ Acknowledge your signature in the presence of two adult witnesses; OR
☐ If you are unable to sign, direct another person to sign on your behalf in your presence and in the presence of two adult witnesses

Each Witness Must:
☐ Be at least 18 years old
☐ Witness either the principal's signing or the principal's acknowledgment of the signature

At Least One Witness Must:
☐ NOT be a relative of the principal by blood, marriage, or adoption
☐ NOT be a person who, at the time the advance directive is signed, would be entitled to any portion of the principal's estate upon death under any will or by operation of law

No Witness May Be:
☐ The appointed Health Care Representative or any alternate Health Care Representative
☐ The principal's attending physician or nurse practitioner at the time the directive is signed

If the Principal Is in a Long-Term Care Facility:
☐ One of the witnesses must be an individual designated by the facility and qualified as specified by the Oregon Department of Human Services by rule (ORS 127.515(3))

Note: Oregon does NOT require notarization of an advance directive, although notarization is recommended for added assurance of validity.

9.2 Signature of Principal

I sign this Advance Directive for Health Care, Do Not Resuscitate preference, Declaration for Mental Health Treatment, and Organ Donation preferences voluntarily, while of sound mind and understanding its contents.

________________________________________
Signature of Principal                 Date: [__/__/____]

________________________________________
Printed Name of Principal

9.3 Witness 1

I declare that the person who signed this document, or asked another to sign for them, did so in my presence, that the person appears to be of sound mind, and that the signing was voluntary. I am at least 18 years of age.

☐ I am NOT related to the principal by blood, marriage, or adoption.
☐ I am NOT entitled to any portion of the principal's estate upon death.
☐ I am NOT the principal's Health Care Representative or alternate.
☐ I am NOT the principal's attending physician or nurse practitioner.

________________________________________
Signature of Witness 1                 Date: [__/__/____]

________________________________________
Printed Name

________________________________________
Address

________________________________________
City, State, ZIP

9.4 Witness 2

I declare that the person who signed this document, or asked another to sign for them, did so in my presence, that the person appears to be of sound mind, and that the signing was voluntary. I am at least 18 years of age.

☐ I am NOT the principal's Health Care Representative or alternate.
☐ I am NOT the principal's attending physician or nurse practitioner.

________________________________________
Signature of Witness 2                 Date: [__/__/____]

________________________________________
Printed Name

________________________________________
Address

________________________________________
City, State, ZIP

9.5 Optional Notarization

STATE OF OREGON
COUNTY OF [________________________________]

On this [____] day of [________________________________], 20[____], before me personally appeared [________________________________], known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that he/she executed the same voluntarily and for the purposes stated therein.

________________________________________
Notary Public for Oregon
My Commission Expires: [__/__/____]

10. PROVIDER ACKNOWLEDGMENT

10.1 Attending Physician / Nurse Practitioner Acknowledgment

I acknowledge that I have received a copy of this advance directive and have reviewed it with the patient. I have placed a copy in the patient's medical record.

Provider Name: [________________________________]

Title: ☐ M.D. ☐ D.O. ☐ N.P. ☐ P.A.

Practice/Facility: [________________________________]

Address: [________________________________]

Phone: [________________________________]

NPI Number: [________________________________]

________________________________________
Provider Signature                     Date: [__/__/____]

10.2 Facility Acknowledgment (If Applicable)

If the principal is a patient in a hospital, nursing facility, assisted living facility, or other health care facility:

Facility Name: [________________________________]

Facility Address: [________________________________]

Acknowledged by: [________________________________]

Title: [________________________________]

________________________________________
Facility Representative Signature      Date: [__/__/____]

11. REVOCATION PROCEDURES

11.1 How to Revoke an Advance Directive (ORS 127.540)

An advance directive may be revoked at any time by the principal in any of the following ways:

☐ Written Revocation -- The principal signs a written revocation. The revocation does not need to be witnessed or notarized.

☐ Oral Revocation -- The principal states orally that the advance directive is revoked. The revocation should be communicated to the attending physician or nurse practitioner, who should document it in the medical record.

☐ Destruction -- The principal destroys the advance directive or directs another person to destroy it in the principal's presence.

☐ Execution of a New Advance Directive -- The principal executes a new advance directive. A later advance directive revokes an earlier one to the extent of any conflict.

11.2 Written Revocation Form

REVOCATION OF ADVANCE DIRECTIVE FOR HEALTH CARE

I, [________________________________], hereby revoke my Advance Directive for Health Care dated [__/__/____].

☐ I revoke the entire advance directive.
☐ I revoke only the following parts: [________________________________]

I understand that this revocation is effective immediately and that I should notify my Health Care Representative, health care providers, and any person or facility that has a copy of the advance directive.

________________________________________
Signature                              Date: [__/__/____]

________________________________________
Printed Name

11.3 Important Notes on Revocation

☐ Revocation is effective immediately, regardless of the principal's mental or physical condition at the time of revocation (ORS 127.540(2))

☐ The principal should make reasonable efforts to notify the Health Care Representative, attending physician, and any health care facility of the revocation

☐ If the advance directive is registered with a health care provider or facility, notify them of the revocation so their records can be updated

☐ Revocation of a POLST form requires a conversation with a health care professional and completion of a new POLST or documentation that the previous POLST is void

12. FILING AND DISTRIBUTION INSTRUCTIONS

12.1 Distribution Checklist

After executing this advance directive, provide copies to all of the following:

☐ Health Care Representative (primary and all alternates)

☐ Attending Physician / Primary Care Provider -- for inclusion in your medical record

☐ Hospital / Health Care Facility -- if you are currently a patient

☐ Family Members -- those who may be involved in your care

☐ Attorney -- for safekeeping with your other legal documents

☐ Clergy / Spiritual Advisor (if desired)

☐ Close Friends / Caregivers who may be present in an emergency

12.2 Storage Recommendations

☐ Keep the original signed document in a safe but accessible location (NOT in a safe deposit box, which may not be accessible in an emergency)

☐ Keep a copy at your home in an easily identifiable location (many people attach it to their refrigerator with their POLST)

☐ Carry a wallet card indicating that you have an advance directive and identifying your Health Care Representative

☐ Upload a copy to your patient portal if your health care provider offers electronic medical records access

☐ Consider registering your advance directive with the Oregon Health Decisions Advance Directive Registry (if available)

12.3 Portability

☐ Oregon advance directives are honored in Oregon and may be honored in other states pursuant to that state's laws regarding out-of-state advance directives

☐ If you move to another state, review your advance directive with an attorney in that state to ensure it complies with local law

☐ If you travel frequently, consider carrying a copy of your advance directive with your identification

12.4 Review and Update Schedule

It is recommended that you review your advance directive:

☐ At least every 2-3 years
☐ After any major change in health status
☐ After any major life event (marriage, divorce, death of Health Care Representative, etc.)
☐ If your wishes about health care change
☐ If your Health Care Representative becomes unavailable or you wish to change them
☐ After hospitalization or surgery

13. PRACTICE NOTES WITH ORS CITATIONS

13.1 Statutory Framework

☐ ORS 127.505 -- Definitions for advance directives, including "advance directive," "health care," "health care decision," "health care representative," "incapable," and "principal"

☐ ORS 127.510 -- Scope: an advance directive may include appointment of a health care representative, instructions for health care, or both

☐ ORS 127.515 -- Execution and witness requirements (detailed in Section 9 above)

☐ ORS 127.520 -- The advance directive becomes operative when the principal's attending physician or nurse practitioner determines that the principal is incapable of making health care decisions. The health care representative may not make decisions before that determination.

☐ ORS 127.525 -- Authority of the health care representative: may make all health care decisions the principal could make, subject to any limitations stated in the directive

☐ ORS 127.530 -- Limitations: the health care representative may not authorize withholding or withdrawing life-sustaining treatment unless the principal is in a terminal condition, permanently unconscious, or a condition substantially similar, and the principal has not given instructions to the contrary

☐ ORS 127.535 -- Obligations of health care providers: a provider who is unwilling to comply with the advance directive must promptly transfer the patient to another provider who will comply

☐ ORS 127.540 -- Revocation procedures (detailed in Section 11 above)

☐ ORS 127.545 -- Good faith immunity: health care providers and health care representatives who act in good faith compliance with an advance directive are immune from civil and criminal liability

☐ ORS 127.555 -- Penalties: it is a Class A misdemeanor to willfully conceal, cancel, deface, or obliterate an advance directive without the principal's consent, or to falsify or forge an advance directive

13.2 POLST Statutes

☐ ORS 127.635 -- Definitions for POLST

☐ ORS 127.640 -- POLST form requirements; must be a standardized form approved by the Oregon Health Authority

☐ ORS 127.649 -- POLST form must be completed by a health care professional based on a discussion with the patient or the patient's decision maker

☐ ORS 127.663 -- Relationship between POLST and advance directive: POLST is a medical order; advance directive is a patient document. Both should be consistent; if there is a conflict, the most recently executed document controls

☐ ORS 127.670 -- Oregon POLST Registry: the Oregon Health Authority maintains a registry of POLST forms

☐ ORS 127.684 -- Immunity for compliance with POLST orders

13.3 Mental Health Declaration Statutes

☐ ORS 127.700 -- Definitions for declarations for mental health treatment

☐ ORS 127.702 -- Authorization to make a declaration for mental health treatment

☐ ORS 127.705 -- When the declaration becomes effective: when the principal is determined to be incapable of making mental health treatment decisions

☐ ORS 127.707 -- Execution requirements: must be signed by the principal and witnessed by two adults (same witness requirements as advance directive)

☐ ORS 127.709 -- Duration: a declaration for mental health treatment is effective for not more than 3 years from the date of execution

☐ ORS 127.712 -- Revocation: may be revoked at any time by the principal when capable

☐ ORS 127.737 -- Immunity for good faith compliance

13.4 Oregon Death with Dignity Act (ORS 127.800-127.897)

☐ Oregon's Death with Dignity Act allows terminally ill Oregon residents to obtain and use prescriptions from their physicians for self-administered lethal doses of medication

☐ The Death with Dignity Act is separate from advance directives and POLST forms

☐ An advance directive cannot be used to request assisted death under the Death with Dignity Act; the Act has its own specific procedures and requirements

☐ A POLST order for DNR does not authorize assisted death

13.5 Practitioner Best Practices

☐ Always advise clients to complete both an advance directive and a POLST (if the client has a serious illness or is elderly)

☐ Ensure witnesses meet all requirements under ORS 127.515, particularly the restriction that at least one witness not be a relative or potential heir

☐ If the client is in a long-term care facility, ensure one witness is a facility-designated individual per ORS 127.515(3)

☐ Advise clients that a POLST must be signed by a licensed health care professional -- an attorney cannot prepare a POLST without physician/NP/PA involvement

☐ Advise clients to register their POLST with the Oregon POLST Registry

☐ Review the client's existing estate planning documents (will, trust, power of attorney) to ensure consistency with the advance directive

☐ If the client has a mental health condition, discuss the Declaration for Mental Health Treatment as an additional planning tool

☐ Remind clients that Oregon recognizes out-of-state advance directives under ORS 127.510(3), but an Oregon-compliant directive is preferable for Oregon residents

14. SOURCES AND REFERENCES

Oregon Statutes

• ORS Chapter 127 -- Powers of Attorney; Advance Directives for Health Care; POLST; Declarations for Mental Health Treatment; Death with Dignity
• ORS 127.505-127.585 -- Advance Directives for Health Care
• ORS 127.635-127.684 -- Physician Orders for Life-Sustaining Treatment (POLST)
• ORS 127.700-127.737 -- Declarations for Mental Health Treatment
• ORS 127.800-127.897 -- Oregon Death with Dignity Act
• ORS 97.954 -- Anatomical Gifts (Organ Donation)

Government and Official Resources

• Oregon Health Authority Advance Directive Form: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le3905.pdf
• Oregon Health Authority Advance Directive Guide: https://sharedsystems.dhsoha.state.or.us/DHSForms/Served/le3942.pdf
• Oregon POLST Program: https://oregonpolst.org
• Oregon POLST Registry: https://polst.oregonpolst.org
• Oregon Legislature (ORS Chapter 127): https://www.oregonlegislature.gov/bills_laws/ors/ors127.html
• Donate Life Northwest (Organ Donation): https://www.donatelifenw.org

Professional Organizations

• Caring Info (National Hospice and Palliative Care Organization): https://www.caringinfo.org
• Oregon State Bar (Elder Law Section)
• Oregon Academy of Family Physicians

COMPLETION CHECKLIST

Use this checklist to ensure all sections have been completed and properly executed:

☐ Part A completed: Health Care Representative appointed (primary and alternates)
☐ Part B completed: Instructions for health care documented
☐ DNR preference indicated
☐ Mental Health Declaration completed (if desired, and within 3-year duration)
☐ Organ donation preferences stated
☐ Advance Directive signed by Principal
☐ Witnessed by two adult witnesses meeting ORS 127.515 requirements
☐ At least one witness is NOT a relative or potential heir
☐ Neither witness is the Health Care Representative or attending physician
☐ Long-term care facility witness requirement met (if applicable)
☐ Optional notarization obtained (recommended)
☐ Copies distributed to Health Care Representative, physician, family, and attorney
☐ Original stored in accessible location
☐ POLST form discussed with health care provider (if appropriate)
☐ POLST signed and registered with Oregon POLST Registry (if appropriate)
☐ Wallet card completed and carried

This template is provided for informational purposes only and does not constitute legal advice. Advance directives and health care planning documents should be prepared in consultation with a qualified attorney and a licensed health care provider. Oregon law has specific requirements for the execution, witnessing, and revocation of advance directives; failure to comply may affect the validity of the document. Verify all statutory citations with current Oregon law before relying on this template.

Last Updated: February 22, 2026