The California Advanced Health Care Directive is a legal document that allows individuals to outline their healthcare preferences in the event they become unable to communicate their wishes. This form empowers individuals to appoint a trusted person to make medical decisions on their behalf and specify their treatment preferences. Understanding and completing this directive can ensure that your healthcare choices are respected when it matters most.
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The California Advanced Health Care Directive is a vital document that allows individuals to outline their medical care preferences in the event they become unable to communicate their wishes. This form encompasses two primary components: the designation of a health care agent and the specification of medical treatment preferences. By appointing a trusted person as a health care agent, individuals ensure that someone they trust will make decisions on their behalf regarding medical treatment. Additionally, the directive allows individuals to express their wishes about life-sustaining treatments, pain management, and other critical health care decisions. This comprehensive approach not only provides clarity for medical professionals but also alleviates the emotional burden on family members during difficult times. The form is designed to be straightforward and accessible, encouraging individuals to engage in conversations about their health care choices. By completing this directive, individuals can assert their autonomy and ensure their preferences are respected, even when they cannot voice them directly.
The California Advanced Health Care Directive is an important document that allows individuals to outline their medical care preferences and designate someone to make healthcare decisions on their behalf. Along with this directive, several other forms and documents can be beneficial for comprehensive healthcare planning. Below is a list of commonly used documents that complement the Advanced Health Care Directive.
Having these documents in place can provide clarity and guidance during critical healthcare decisions. It is essential to review and update them regularly to reflect any changes in your preferences or circumstances.
ADVANCE HEALTH CARE DIRECTIVE FORM
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Probate Code - PROB
DIVISION 4.7. HEALTH CARE DECISIONS [4600 - 4806] ( Division 4.7 added by Stats. 1999, Ch. 658, Sec. 39. ) PART 2. UNIFORM HEALTH CARE DECISIONS ACT [4670 - 4743] ( Part 2 added by Stats. 1999, Ch. 658, Sec. 39. )
CHAPTER 2. Advance Health Care Directive Forms [4700 - 4701] ( Chapter 2 added by Stats. 1999, Ch. 658, Sec. 39. )
4701. The statutory advance health care directive form is as follows:
ADVANCE HEALTH CARE DIRECTIVE
(California Probate Code Section 4701)
Explanation
You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.
Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. (Your agent may not be an operator or employee of a community care facility or a residential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker.)
Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:
(a)Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition.
(b)Select or discharge health care providers and institutions.
(c)Approve or disapprove diagnostic tests, surgical procedures, and programs of medication.
(d)Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation.
(e)Donate your organs, tissues, and parts, authorize an autopsy, and direct disposition of remains.
Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out Part 2 of this form.
Part 3 of this form lets you express an intention to donate your bodily organs, tissues, and parts following your death.
Part 4 of this form lets you designate a physician to have primary responsibility for your health care.
After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.
You have the right to revoke this advance health care directive or replace this form at any time.
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PART 1
POWER OF ATTORNEY FOR HEALTH CARE
(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me:
(name of individual you choose as agent)
(address)
(city)
(state)
(ZIP Code)
(home phone)
(work phone)
OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate agent:
(name of individual you choose as first alternate agent)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent:
(name of individual you choose as second alternate agent)
(1.2) AGENT'S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:
(Add additional sheets if needed.)
(1.3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box.
If I mark this box , my agent's authority to make health care decisions for me takes effect immediately.
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(1.4.) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.
(1.5) AGENT'S POSTDEATH AUTHORITY: My agent is authorized to donate my organs, tissues, and parts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:
:
(1.6) NOMINATION OF CONSERVATOR: If a conservator of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not wiling, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated.
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you fill out this part of the form, you may strike any wording you do not want.
(2.1) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:
(a) Choice Not to Prolong Life
I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR
(b) Choice to Prolong Life
I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
(2.2) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:
(2.3) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:
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PART 3
DONATION OF ORGANS, TISSUES, AND PARTS AT DEATH
(OPTIONAL)
(3.1)
Upon my death, I give my organs, tissues, and parts (mark box to indicate yes).
By checking the box above, and notwithstanding my choice in Part 2 of this form, I authorize my agent to consent to any temporary medical procedure necessary solely to evaluate and/or maintain my organs, tissues, and/or parts for purposes of donation.
My donation is for the following purposes (strike any of the following you do not want):
(a)Transplant
(b)Therapy
(c)Research
(d)Education
If you want to restrict your donation of an organ, tissue, or part in some way, please state your restriction on the following lines:
If I leave this part blank, it is not a refusal to make a donation. My state-authorized donor registration should be followed, or, if none, my agent may make a donation upon my death. If no agent is named above, I acknowledge that California law permits an authorized individual to make such a decision on my behalf. (To state any limitation, preference, or instruction regarding donation, please use the lines above or in Section 1.5 of this form).
PART 4
PRIMARY PHYSICIAN
(4.1) I designate the following physician as my primary physician:
(name of physician)
(phone)
OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician:
PART 5
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(5.1) EFFECT OF COPY: A copy of this form has the same effect as the original.
(5.2) SIGNATURE: Sign and date the form here:
(date)
(sign your name)
(print your name)
(city) (state)
(5.3) STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and (5) that I am not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly.
First witness
Second witness
(print name)
(city)(state)
(signature of witness)
(5.4) ADDITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration:
I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law.
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PART 6
SPECIAL WITNESS REQUIREMENT
(6.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following statement:
STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN
I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am serving as a witness as required by Section 4675 of the Probate Code.
(Amended by Stats. 2018, Ch. 287, Sec. 1. (AB 3211) Effective January 1, 2019.)
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ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California,
County of
On
before me,
(insert name and title of officer)
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person
(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature
(SEAL)
Filling out the California Advanced Health Care Directive form is an important step in planning for future medical care. This form allows individuals to express their wishes regarding medical treatment and appoint someone to make decisions on their behalf if they are unable to do so. Below are the steps to complete the form effectively.
The California Advanced Health Care Directive form is similar to a Living Will. A Living Will allows individuals to specify their preferences regarding medical treatment in situations where they are unable to communicate their wishes. Both documents serve to ensure that a person's healthcare choices are respected, particularly in end-of-life scenarios. While a Living Will focuses primarily on medical treatment preferences, the Advanced Health Care Directive can also appoint a healthcare agent to make decisions on behalf of the individual.
An additional document that shares similarities is the Durable Power of Attorney for Health Care. This document grants authority to a designated person to make healthcare decisions if the individual becomes incapacitated. Like the Advanced Health Care Directive, it allows for the appointment of a healthcare proxy. However, the Durable Power of Attorney for Health Care is specifically limited to health-related decisions, whereas the Advanced Health Care Directive encompasses both health care preferences and the appointment of an agent.
In drafting essential legal documents, such as the Operating Agreement form for LLCs, it's crucial to have access to reliable resources. Utilizing platforms like legalpdf.org can facilitate the creation of these documents and help ensure compliance with state-specific requirements, ultimately leading to better governance and clarity in business operations.
The Do Not Resuscitate (DNR) Order is another document that parallels the California Advanced Health Care Directive. A DNR order specifically instructs medical personnel not to perform CPR if a person's heart stops or they stop breathing. While the Advanced Health Care Directive can include broader health care preferences, a DNR focuses solely on resuscitation efforts. Both documents aim to reflect the individual's wishes regarding life-sustaining treatment.
The Physician Orders for Life-Sustaining Treatment (POLST) form is also comparable. POLST is a medical order that outlines a patient's preferences for treatment in emergency situations. It is designed for individuals with serious health conditions. Like the Advanced Health Care Directive, the POLST form is intended to ensure that medical personnel follow the patient’s wishes regarding treatment. However, POLST is more immediate and actionable in emergency settings, while the Advanced Health Care Directive can cover a wider range of scenarios.
The Health Care Proxy form is another similar document. This form allows an individual to appoint someone to make health care decisions on their behalf if they are unable to do so. The Health Care Proxy is closely related to the appointment aspect of the Advanced Health Care Directive. However, it may not include specific treatment preferences, which are often detailed in the Advanced Health Care Directive.
Finally, the Mental Health Advance Directive is akin to the California Advanced Health Care Directive but focuses on mental health treatment. This document allows individuals to express their preferences regarding mental health care and appoint a representative to make decisions during a mental health crisis. Both directives empower individuals to take control of their healthcare decisions, but the Mental Health Advance Directive specifically addresses mental health issues, while the Advanced Health Care Directive encompasses a broader range of medical treatments.
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Understanding the California Advanced Health Care Directive is essential for making informed decisions about medical care. However, several misconceptions can lead to confusion. Here are six common misconceptions:
This form is beneficial for anyone, regardless of age. Unexpected health issues can arise at any time, making it important for all adults to have a plan in place.
While legal advice can be helpful, individuals can complete the directive on their own. The form is designed to be user-friendly and accessible.
The directive encompasses a range of medical decisions, not just those related to end-of-life care. It can address preferences for treatments, procedures, and more.
People have the right to update or revoke their directive at any time. Life circumstances and preferences may change, and the form should reflect that.
While both documents deal with medical preferences, the California Advanced Health Care Directive combines elements of a living will and a power of attorney for health care, providing broader coverage.
The directive must be signed in the presence of either a notary public or two witnesses. This requirement helps ensure the document's validity and authenticity.
Addressing these misconceptions can empower individuals to take charge of their health care decisions. Understanding the California Advanced Health Care Directive is a step towards ensuring that your wishes are respected.