The California Advanced Health Care Directive form is a legal document that allows individuals to outline their healthcare preferences in the event they become unable to communicate their wishes. This directive empowers you to appoint a trusted person to make medical decisions on your behalf and to specify your treatment preferences. Taking the time to fill out this important form ensures that your values and desires are honored when it matters most, so click the button below to get started.
The California Advanced Health Care Directive is a vital legal document that empowers individuals to make their healthcare preferences known in advance. This form allows you to appoint a trusted person, known as an agent, to make medical decisions on your behalf if you become unable to do so. It also provides an opportunity to outline specific wishes regarding medical treatment, life-sustaining measures, and end-of-life care. By completing this directive, you ensure that your values and preferences are respected, even when you cannot communicate them. The document is designed to be straightforward, allowing you to express your desires clearly and comprehensively. Understanding the importance of this directive can help you navigate the complexities of healthcare decisions and provide peace of mind for both you and your loved ones.
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)
Completing the California Advanced Health Care Directive form is an important step in ensuring that your healthcare preferences are known and respected. This document allows you to appoint someone to make medical decisions on your behalf if you become unable to do so. Following the steps below will help you fill out the form accurately.
What is a California Advanced Health Care Directive?
A California Advanced Health Care Directive is a legal document that allows individuals to express their healthcare preferences in advance. It enables you to appoint someone to make medical decisions on your behalf if you become unable to communicate your wishes. This directive can help ensure that your healthcare choices are honored, even when you cannot voice them yourself.
Who can create an Advanced Health Care Directive in California?
Any adult who is 18 years or older and of sound mind can create an Advanced Health Care Directive in California. This means you should understand the nature of the document and the consequences of your decisions. It’s important to consider your values and preferences when drafting this directive.
What are the key components of the form?
The California Advanced Health Care Directive typically includes two main parts: the appointment of an agent and the declaration of your healthcare preferences. In the first part, you designate a person (your agent) to make medical decisions for you. The second part allows you to outline your wishes regarding medical treatments, life-sustaining measures, and other healthcare-related decisions.
Do I need a lawyer to create an Advanced Health Care Directive?
No, you do not need a lawyer to create an Advanced Health Care Directive in California. However, it is advisable to seek legal assistance if you have specific questions or complex situations. Many resources are available, including templates and guides, to help you complete the form on your own.
How do I ensure my Advanced Health Care Directive is valid?
To ensure your Advanced Health Care Directive is valid in California, you must sign the document in the presence of either a notary public or two witnesses. The witnesses cannot be your agent, your healthcare provider, or anyone who would benefit financially from your death. This step is crucial to confirm that the directive reflects your true wishes.
Can I change or revoke my Advanced Health Care Directive?
Yes, you can change or revoke your Advanced Health Care Directive at any time, as long as you are mentally competent. To make changes, you can create a new directive or modify the existing one. If you decide to revoke it, notify your agent and any healthcare providers involved in your care to ensure they are aware of your decision.
What happens if I do not have an Advanced Health Care Directive?
If you do not have an Advanced Health Care Directive and become unable to make your own medical decisions, your healthcare providers may turn to your family members or close relatives for guidance. However, this can lead to confusion and disagreements among family members about your wishes. Having a directive in place can help avoid such situations and ensure that your preferences are respected.
Can my healthcare provider refuse to follow my Advanced Health Care Directive?
In general, healthcare providers are required to follow your Advanced Health Care Directive as long as it complies with California law. However, if a provider has moral or ethical objections to certain treatments, they may refuse to provide them. In such cases, they should refer you to another provider who is willing to honor your wishes.
Where should I keep my Advanced Health Care Directive?
It is important to keep your Advanced Health Care Directive in a safe but accessible place. Share copies with your designated agent, family members, and healthcare providers. Additionally, consider keeping a copy in your medical records or with your primary care physician to ensure that it is readily available when needed.
Filling out the California Advanced Health Care Directive form can be a crucial step in ensuring that your healthcare wishes are respected. However, many people make common mistakes that can lead to confusion or even legal issues down the line. Understanding these mistakes can help you avoid them.
One frequent error is not discussing your wishes with your appointed agent. It's essential that the person you choose to make decisions on your behalf understands your preferences. Without this conversation, they may struggle to make choices that align with your values.
Another mistake is leaving the form incomplete. Failing to fill out all required sections can create ambiguity. For instance, if you don’t specify your preferences for life-sustaining treatments, healthcare providers may not know how to proceed in a critical situation.
People often forget to sign and date the document. A signature is necessary for the directive to be valid. Without it, your wishes may not be honored, leading to unwanted treatments or interventions.
Not having witnesses present when signing the form is another common oversight. California law requires that your directive be signed in the presence of two witnesses or notarized. Skipping this step can render the document invalid.
Some individuals neglect to update their directive as their circumstances change. Life events such as marriage, divorce, or the death of a designated agent can impact your choices. Regularly reviewing and updating your directive ensures it reflects your current wishes.
Additionally, many people do not provide copies of the completed directive to their healthcare providers or family members. Sharing this document is crucial. It allows everyone involved to be aware of your wishes, reducing the likelihood of disputes during difficult times.
Lastly, misunderstanding the scope of the directive can lead to issues. Some individuals think it only covers end-of-life decisions, but it also includes preferences for medical treatment in various situations. Being clear about your intentions can help ensure that your healthcare choices are respected.
When planning for future healthcare decisions, the California Advanced Health Care Directive form is a crucial document. However, it's important to understand that it often works in conjunction with other forms and documents. Each of these plays a significant role in ensuring that your healthcare wishes are honored and that your loved ones are prepared to make decisions on your behalf if necessary.
Understanding these documents and how they interact with the California Advanced Health Care Directive is essential for effective healthcare planning. By preparing these forms, you ensure that your healthcare preferences are clear, and you provide peace of mind for yourself and your loved ones.
The California Advanced Health Care Directive form is a crucial document for individuals wishing to outline their healthcare preferences. It shares similarities with several other documents that serve similar purposes in the realm of healthcare and personal decision-making. Below are nine documents that are comparable to the California Advanced Health Care Directive:
When filling out the California Advanced Health Care Directive form, consider the following dos and don'ts:
The California Advanced Health Care Directive form is an important legal document that allows individuals to express their healthcare preferences in advance. However, there are several misconceptions surrounding this form that can lead to confusion. Here are four common misconceptions:
Understanding these misconceptions can help individuals make informed decisions about their healthcare preferences and ensure their wishes are honored when they cannot speak for themselves.
When considering the California Advanced Health Care Directive form, it's important to understand its purpose and how to effectively complete it. Here are some key takeaways:
By following these guidelines, you can create a clear and effective Advanced Health Care Directive that reflects your healthcare wishes.