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In California, planning for future health care needs is an important step in ensuring that your medical preferences are honored, especially in times of crisis. One essential tool for this planning is the California Advanced Health Care Directive form. This form allows individuals to express their wishes regarding medical treatment in case they become unable to communicate those wishes themselves. It provides a means to appoint a health care agent who can make decisions on your behalf, ensuring that someone you trust is advocating for your preferences. The form also includes options to specify what types of medical interventions you would want or not want, such as life-sustaining treatments or pain management. By completing this directive, individuals can create a roadmap for their future health care, reducing uncertainty for loved ones and medical professionals. Understanding how to properly fill out this form, including the legal requirements and considerations, can empower you to make informed choices that align with your values.

Sample - California Advanced Health Care Directive Form

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.

ADVANCE HEALTH CARE DIRECTIVE FORM

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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)

(address)

(city)

(state)

(ZIP Code)

 

 

 

 

 

 

(home phone)

(work phone)

 

 

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)

(address)

(city)

(state)

(ZIP Code)

 

 

 

 

 

 

(home phone)

(work phone)

 

 

(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.

ADVANCE HEALTH CARE DIRECTIVE FORM

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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:

:

(Add additional sheets if needed.)

(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:

(Add additional sheets if needed.)

(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:

(Add additional sheets if needed.)

 

ADVANCE HEALTH CARE DIRECTIVE FORM

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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

(OPTIONAL)

(4.1) I designate the following physician as my primary physician:

(name of physician)

(address)

(city)

(state)

(ZIP Code)

(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:

(name of physician)

(address)

(city)

(state)

(ZIP Code)

(phone)

ADVANCE HEALTH CARE DIRECTIVE FORM

PART 5

PAGE 5 of 7

(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)

(address)

(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)

(address)

(city)(state)

(print name)

(address)

(city)(state)

(signature of witness)

(signature of witness)

(date)

(date)

(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.

(signature of witness)

(signature of witness)

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 6 of 7

 

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.

(date)

(sign your name)

(address)

(print your name)

(city) (state)

 

(Amended by Stats. 2018, Ch. 287, Sec. 1. (AB 3211) Effective January 1, 2019.)

ADVANCE HEALTH CARE DIRECTIVE FORM

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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)

 

 

 
↓ California Advanced Health Care Directive PDF

File Specs

Fact Name Description
Legal Requirement The California Advanced Health Care Directive is governed by California Probate Code Sections 4700-4806.
Purpose This form allows individuals to express their healthcare preferences and appoint an agent to make medical decisions on their behalf if they are unable to do so.
Witness Requirement Two witnesses or a notary public must sign the directive to make it legally valid.
Revocation A person can revoke their directive at any time, either verbally or in writing, as long as they communicate this decision clearly.

California Advanced Health Care Directive - Usage Guidelines

Filling out the California Advanced Health Care Directive form is an important step in ensuring your health care wishes are known and respected. This process allows you to express what kind of medical treatment you want and appoint someone to make decisions on your behalf if you are unable to do so. The next steps provide clear guidance on how to complete the form accurately.

  1. Obtain a copy of the California Advanced Health Care Directive form. You can find it online or request a physical copy from your health care provider.
  2. Read through the entire form carefully to understand its sections and requirements.
  3. In the first section, choose your health care agent. This person will make medical decisions for you if you cannot speak for yourself. Write their name and contact information in the designated space.
  4. In the second section, indicate your wishes about medical treatments. You can specify what types of treatment you do or do not want, such as life-sustaining measures.
  5. Review the additional options provided regarding organ donation and other preferences. Mark your choices clearly.
  6. Sign and date the form. Ensure that you do this in front of a witness or notary, as required, to make the form legally valid.
  7. Provide copies of the completed form to your health care agent, family members, and your doctor. This helps ensure everyone is aware of your wishes.

Your Questions, Answered

What is a California Advanced Health Care Directive?

The California Advanced Health Care Directive is a legal document that allows individuals to express their healthcare preferences and appoint an agent to make medical decisions on their behalf in case they become incapacitated. This directive is essential for ensuring that your wishes regarding medical treatment are known and respected, even when you cannot communicate them yourself.

How do I complete the California Advanced Health Care Directive?

To complete the directive, you can obtain a form through various sources, including healthcare providers or legal aid offices. The form typically requires you to fill out personal information, designate a healthcare agent, and specify your preferences for treatments, including life-sustaining procedures. It is crucial to sign the document in front of a witness or notary, depending on state requirements, to validate it.

Can I change or revoke my Advanced Health Care Directive?

Absolutely. You retain the right to modify or cancel your directive at any time, as long as you are of sound mind. To make changes, simply draft a new directive or create a written notice stating your intention to revoke the existing one. It’s advisable to inform your healthcare agent and any relevant medical personnel about your changes to ensure your latest wishes are honored.

Who can serve as my healthcare agent?

Your healthcare agent must be an adult who you trust to make medical decisions for you. This person can be a family member, friend, or even a legal representative. It is essential to discuss your values and preferences with this individual to ensure they can make informed decisions that align with your wishes in a medical crisis.

What types of medical decisions can my agent make?

Your appointed agent can make a wide range of healthcare decisions on your behalf, including choices about medical treatments, surgery, end-of-life care, and more. Your directive should clearly outline any specific preferences or limits regarding what you would or would not want, which will guide your agent in making decisions that reflect your values.

Is a California Advanced Health Care Directive recognized in other states?

Generally, yes, a California Advanced Health Care Directive is recognized in other states. However, the laws regarding advanced directives can vary, so it’s wise to check the specific regulations of the state in question. If you frequently travel or relocate, you may want to consider creating a directive that meets the legal requirements of other states to ensure it remains valid.

What happens if I don’t have an Advanced Health Care Directive?

If you do not have an Advanced Health Care Directive and become incapacitated, your loved ones or healthcare providers may face challenges in making decisions on your behalf. Without clear guidance, they may feel uncertain or conflicted about your preferences. This can lead to delays in care, disagreements, or actions that may not align with your wishes. Establishing a directive helps mitigate these potential issues and ensures your voice is heard.

Common mistakes

  1. Not completing all sections: It is crucial to fill out every part of the form. Leaving sections blank can create confusion and may not reflect your wishes accurately.

  2. Using outdated forms: Ensure you use the most current version of the Advanced Health Care Directive form. Laws and regulations may change, so using an old form could lead to issues.

  3. Not signing the document: Failing to sign the directive is a common oversight. Without your signature, the directive holds no legal weight.

  4. Missing witness signatures: It’s important to have the required witnesses sign the document. Their signatures verify that you signed it willingly and without coercion.

  5. Choosing the wrong agent: Carefully consider your choice of agent. This person will make critical health care decisions on your behalf, so they should fully understand your values and wishes.

  6. Providing vague instructions: Be as specific as possible in your choices and instructions. Vague language can lead to misunderstandings about what you want.

  7. Not discussing your wishes: It’s a mistake to fill out the form without having conversations with your loved ones and your agent. Clear communication helps ensure your wishes are honored.

  8. Failing to update the directive: Life circumstances change, and so do your health care preferences. Regularly review and update your directive to make sure it reflects your current wishes.

Documents used along the form

The California Advanced Health Care Directive is a crucial document that allows individuals to outline their healthcare preferences and appoint someone to make medical decisions on their behalf if they become unable to do so. When preparing such an important directive, it's often helpful to consider other related forms and documents that can provide additional clarity and support in healthcare decision-making.

  • Durable Power of Attorney for Health Care: This document allows individuals to designate a specific person to make healthcare decisions if they are incapacitated. It establishes a legal authority for the chosen representative.
  • HIPAA Release Form: This form grants permission for specific individuals to access your medical records. It is essential for ensuring that your appointed healthcare agent can make informed decisions on your behalf.
  • Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR if a patient's heart or breathing stops. This document reflects a person's wishes regarding life-sustaining treatment.
  • POLST (Physician Orders for Life-Sustaining Treatment): This document translates an individual's wishes about life-sustaining treatment into actionable medical orders. It is typically used for patients with serious illnesses or those nearing the end of life.
  • Living Will: A living will specifies an individual's preferences for medical treatment in the event of a terminal condition or persistent vegetative state. It is a way to communicate wishes about end-of-life care.
  • Health Care Proxy: This document allows someone else to make medical decisions on your behalf during any incapacitation. Unlike a durable power of attorney, it is specifically limited to healthcare decisions.
  • Personal Health Record: A personal health record compiles crucial information about your medical history, medications, and allergies. This document helps caregivers make informed decisions and ensures continuity of care.
  • Risk Acceptance Form: This form is used to acknowledge understanding and acceptance of risks associated with specific medical procedures or treatments, ensuring informed consent.
  • Organ Donation Registration: This document records a person's wishes regarding organ donation after death. It serves as a clear directive to family members and medical personnel.
  • Beneficiary Designation Forms: While not directly related to healthcare, these forms specify who will receive assets after one’s death. They can be relevant for overall end-of-life planning and decisions.

Considering these additional documents can ensure that your healthcare preferences are respected and understood. Proper planning and documentation can alleviate family stress during difficult times and ensure that your wishes are clearly articulated and followed.

Similar forms

The California Advanced Health Care Directive serves as a crucial document for individuals seeking to outline their medical care preferences when they can no longer communicate those wishes. It shares similarities with a Living Will, which specifically addresses an individual’s preferences concerning life-sustaining treatments and procedures in the face of terminal illness or irreversible conditions. Both documents emphasize a person's right to refuse or accept medical interventions, ensuring that their values and desires guide treatment decisions even in moments of incapacity.

Another document akin to the Advanced Health Care Directive is a Durable Power of Attorney for Health Care. This legal form designates a specific person to make medical decisions on behalf of someone who cannot communicate their wishes. While the Advanced Health Care Directive may include such designations, the Durable Power of Attorney for Health Care focuses solely on appointing a representative. Both documents work together to create a comprehensive approach to health care decision-making.

The Medical Power of Attorney also parallels the Advanced Health Care Directive. Like the Durable Power of Attorney for Health Care, it allows individuals to appoint a proxy to make medical decisions based on the patient’s preferences. However, the Medical Power of Attorney tends to be broader, often encompassing decisions beyond just end-of-life scenarios, thus creating a wider net of authority for the appointed agent.

A Do Not Resuscitate (DNR) order is another document with similarities to the Advanced Health Care Directive. A DNR specifically instructs medical personnel not to perform CPR if a patient's heart stops. While the DNR focuses on one aspect of medical care—resuscitation—the Advanced Health Care Directive can encapsulate broader preferences, including various treatment options and palliative care preferences.

The Physician Orders for Life-Sustaining Treatment (POLST) is also comparable. POLST complements an Advanced Health Care Directive by translating an individual’s wishes regarding treatment into a medical order. This document is particularly effective for patients with serious medical conditions, allowing them to establish specific goals of care. Both documents work in tandem to ensure that medical instructions are clear and respected in urgent situations.

Another related document is a Health Care Proxy. The Health Care Proxy facilitates the appointment of a person to make healthcare decisions on behalf of another. While very similar to the Durable Power of Attorney for Health Care, the Health Care Proxy is often used interchangeably and emphasizes a patient’s personal choice of an agent to advocate for their medical needs in line with their expressed wishes.

Finally, a Living Trust may contain provisions related to health care decisions, although it primarily focuses on financial matters and asset management. However, some individuals use a Living Trust to include directives for health care, making it another potential avenue for outlining personal preferences concerning medical treatment. Despite its primary function, the inclusion of health care options indicates a comprehensive approach to ensuring personal wishes are respected across both financial and health domains.

Dos and Don'ts

When filling out the California Advanced Health Care Directive form, follow these guidelines for a smooth process.

  • Do: Read the entire form carefully before starting.
  • Do: Use clear and concise language.
  • Do: Make sure you are of sound mind when signing.
  • Do: Discuss your decisions with your healthcare agent.
  • Do: Date and sign the document in front of a witness.
  • Don't: Rush through the form—take your time.
  • Don't: Leave any blank spaces; fill everything out completely.
  • Don't: Forget to inform your healthcare providers about your directive.
  • Don't: Use technical medical terms unless necessary.
  • Don't: Assume your wishes are understood without discussing them.

Misconceptions

Understanding the California Advanced Health Care Directive form is crucial for ensuring that your medical wishes are respected in times of need. Here are some common misconceptions about this important document:

  • The form is only for elderly individuals. Many people believe that advanced directives are only necessary for older adults. In reality, anyone over the age of 18 can complete this form. Accidents and unexpected health issues can happen at any age.
  • The directive is legally binding regardless of the circumstances. While the California Advanced Health Care Directive is designed to be a legally binding document, there are specific situations where it may not be honored. Changes in mental capacity or the healthcare provider’s judgment may affect how the directive is implemented.
  • Once it’s signed, it can’t be changed. This misconception can prevent individuals from completing the form. In fact, you can change or revoke your Advanced Health Care Directive at any time, as long as you are mentally competent. Regular review and updates are encouraged to reflect your current wishes.
  • It only covers end-of-life decisions. While many associate the directive with end-of-life care, it also allows individuals to express their preferences for medical treatment in a variety of situations, including during serious illness or injury. It can guide decisions on life support, specific treatments, and more.

Clarifying these misconceptions can help ensure that your healthcare preferences are understood and honored. It is always advisable to consult with a legal or healthcare professional when filling out such important documents.

Key takeaways

Understanding the California Advanced Health Care Directive form is essential for making informed decisions about your medical care. Here are key takeaways for filling it out and using it:

  • The form allows you to appoint someone as your health care agent. This person will make medical decisions on your behalf if you are unable to do so.
  • You can specify your health care wishes directly in the form. These preferences can guide your agent and medical providers in critical situations.
  • The Directive remains valid until you revoke it. It’s important to review and update it regularly, especially after significant life changes.
  • Witnesses or notarization are required for the form to be legally binding. Be sure to follow the rules to ensure your wishes are honored.

Using this Directive empowers you and ensures your voice is heard in health care decisions, even when you cannot speak for yourself.

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