California Advanced Health Care Directive Template

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 directive enables a person to appoint a trusted individual to make medical decisions on their behalf, ensuring that their values and preferences are respected. Navigating the complexities of healthcare decisions is essential; take the first step by accurately completing this important form.

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Content Overview

In the landscape of healthcare planning, the California Advanced Health Care Directive form plays a critical role, empowering individuals to make informed decisions about their medical care in advance. This legal document allows you to designate a healthcare agent, someone you trust, to make decisions on your behalf if you become unable to communicate your wishes. Equally important, the directive lets you articulate your specific healthcare preferences, covering a range of procedures and treatments. It encompasses important aspects such as end-of-life care, life-support measures, and other medical interventions. By clearly outlining your desires, you not only guide your loved ones but also relieve them from the burden of making difficult decisions in times of stress. Understanding the components and significance of this directive is essential for anyone looking to secure their health care choices in the event of illness or incapacity.

California Advanced Health Care Directive Sample

ADVANCE HEALTH CARE DIRECTIVE FORM		PAGE 1 of 7
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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	PAGE 4 of 7
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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)

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 Form

Document Attributes

Fact Name	Description
Purpose	The California Advanced Health Care Directive allows individuals to outline their medical care preferences in case they become unable to communicate their wishes.
Governing Law	This form is governed by the California Probate Code Sections 4600 to 4806.
Components	It includes two main components: a Power of Attorney for health care decisions and instructions for medical treatment preferences.
Signing Requirements	The document must be signed by the individual and witnessed by two adults or notarized.
Revocation	Individuals can revoke the directive at any time while they are competent, simply by notifying their health care provider.
Eligibility	Any adult over the age of 18 can complete and execute the directive, as long as they are of sound mind.

California Advanced Health Care Directive: Usage Instruction

Completing the California Advanced Health Care Directive form involves several key steps that require careful consideration. Gathering necessary information and understanding the choices is crucial to ensure personal values and preferences are accurately represented.

Obtain a copy of the California Advanced Health Care Directive form. This can be done online or through healthcare providers.
Review the instructions provided with the form for guidance on completion.
Designate an individual as your healthcare agent. This person will make medical decisions on your behalf when you are unable to do so.
Fill in the personal information section, including your name, address, and contact details.
Clearly outline your health care preferences in the directive section, specifying any treatments you wish to receive or avoid.
Consider your wishes regarding organ donation and indicate your preferences on the form as necessary.
Sign and date the form in the designated spaces. Signature should be done in the presence of a witness or notary public, as required.
Provide copies of the completed directive to your healthcare agent, family members, and healthcare providers to ensure they are aware of your preferences.
Store the original document in a secure yet accessible place for future reference.

Frequently Asked Questions

What is a California Advanced Health Care Directive?
The California Advanced Health Care Directive is a legal document that allows individuals to outline their healthcare preferences in the event that they are unable to communicate those wishes themselves. It combines two key components: a directive for healthcare decisions and a power of attorney for healthcare.
Who should complete an Advanced Health Care Directive?
Any adult who wants to ensure their healthcare preferences are followed should consider completing this directive. It is particularly important for individuals with serious illnesses or those who wish to plan for future medical situations.
What are the key elements of the directive?
The directive typically includes:
- Your healthcare preferences regarding treatment options.
- The name of a trusted person to make healthcare decisions for you if you are unable.
- Instructions on the use of life-sustaining treatment.
How do I choose an agent to make decisions on my behalf?
Choose someone you trust to make healthcare decisions in alignment with your wishes. This person should be willing to act in your best interest and be comfortable discussing your healthcare preferences. It’s good to have an open conversation with them about your values and wishes.
Do I need a lawyer to complete the form?
No, you do not need a lawyer to complete the California Advanced Health Care Directive. However, consulting a legal professional can help ensure that the document meets all legal requirements and addresses your unique needs.
How do I ensure my Advanced Health Care Directive is valid?
To make the directive valid in California, you must sign the document in front of two witnesses or a notary public. Both witnesses must be at least 18 years old and cannot be your health care provider or anyone who stands to benefit from your estate.
Can I change or revoke my Advanced Health Care Directive?
Yes, you can change or revoke your directive at any time as long as you are mentally competent. To make changes, you must create a new directive or formally revoke the existing one in writing. Inform your agent and any healthcare providers of these changes.
What should I do once I complete the form?
After completing your Advanced Health Care Directive, share copies with your healthcare provider, your chosen agent, and family members. Keep the original in a safe place where it can be easily accessed if needed.

Common mistakes

When completing the California Advanced Health Care Directive form, individuals often make several common mistakes that can lead to complications in medical decision-making. Awareness of these errors can help ensure the document reflects personal wishes accurately.

One common mistake is failing to designate an appropriate health care agent. Many people choose someone close to them, such as a family member or friend, without considering whether that person understands their values and preferences. Choosing a decision-maker who can advocate effectively is crucial.

Another frequent error involves not discussing the directive with the chosen agent. Clear communication ensures that the agent understands their responsibilities and the individual’s wishes regarding medical treatments. Without this conversation, misunderstandings may arise during critical moments.

Some individuals overlook the importance of being specific about their medical preferences. A vague description of desired treatments can lead to confusion or may not align with the current medical landscape. Providing detailed information helps ensure that health care providers understand what is acceptable.

Another mistake is neglecting to sign and date the form. Even if the form is filled out completely, it may not be legally valid without a signature. Additionally, failing to have witnesses or a notary can also impact the form's acceptance in a medical setting.

People sometimes forget to update their directive after significant life events, such as divorces or the death of a designated agent. Regularly reviewing and revising the directive to reflect current circumstances is essential for maintaining its relevance and effectiveness.

Some individuals do not provide copies of the completed directive to their agent or health care providers. Sharing these copies ensures that everyone involved is aware of and can access the document when necessary. Without copies, delays may occur in implementing the wishes stated in the directive.

Lastly, failing to understand state-specific laws related to the directive can lead to unexpected issues. While the California version has unique requirements, individuals may incorrectly assume that a directive from another state or a generic form will suffice. Familiarity with local regulations is vital for the directive to be enforceable.

Documents used along the form

The California Advanced Health Care Directive is a vital document for those wanting to outline their medical care preferences and appoint a trusted individual to make decisions on their behalf should they become unable to do so. However, this document often works alongside several other important legal forms and documents, enhancing clarity and support for individuals' healthcare choices. Below is a list of related documents that complement the health care directive.

Durable Power of Attorney for Health Care: This form allows individuals to designate someone to make healthcare decisions on their behalf. It provides authoritative guidance concerning medical treatment choices in case of incapacitation.
Living Will: A living will outlines specific medical treatments individuals wish to receive or forego in the event they are unable to communicate their preferences. It typically focuses on end-of-life scenarios or situations of irreversible conditions.
Do Not Resuscitate (DNR) Order: A DNR order instructs medical staff not to perform CPR if a person stops breathing or their heart ceases to beat. This document reflects a person's wishes regarding resuscitation in a clear and formal manner.
Organ Donation Form: This document specifies an individual's wishes regarding organ and tissue donation after death. It can clarify decisions made concerning life-saving measures and reflects one's commitment to helping others.
HIPAA Authorization Form: The Health Insurance Portability and Accountability Act (HIPAA) form grants permission for healthcare providers to share an individual's medical information with specified individuals. This ensures privacy while allowing loved ones to be informed about important health matters.
Health Care Proxy: Similar to a durable power of attorney for healthcare, a health care proxy designates an agent to make medical decisions. However, it is often used more informally and may vary by state regulations.
Physician Orders for Life-Sustaining Treatment (POLST): POLST forms are medical orders that dictate the types of life-sustaining treatment a person desires. This document aims to ensure healthcare professionals adhere to patients' wishes in emergency situations.
Emergency Medical Services (EMS) Card: This card provides vital information about an individual’s medical history, allergies, and directives that first responders should follow in emergencies. It can support quick medical assessment in critical situations.
Medical Record Release Form: This form allows individuals to authorize the release of their medical records to designated parties, enabling family members or appointed agents to access treatment history when needed.

Exploring these documents helps ensure that your healthcare wishes are honored, even when you cannot express them personally. Each form offers distinct benefits while providing a comprehensive approach to managing health-related decisions. By understanding and utilizing these documents, individuals can enhance their preparedness for unforeseen circumstances regarding their health and wellbeing.

Similar forms

The California Advanced Health Care Directive form is a significant document for making healthcare decisions. However, it shares similarities with several other legal documents designed to outline individual preferences regarding health care and decision-making. Here are seven documents that align closely with the provisions found in the California Advanced Health Care Directive:

Living Will: A living will specifies an individual's wishes regarding medical treatment in situations where they are unable to communicate their preferences, particularly in cases of terminal illness or irreversible coma.
Durable Power of Attorney for Health Care: This document designates someone to make healthcare decisions on behalf of an individual if they become incapacitated, ensuring choices align with the individual's values and desires.
Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR if the person's breathing or heartbeat stops, reflecting their preferences regarding lifesaving measures.
Physician Orders for Life-Sustaining Treatment (POLST): This document outlines a person's wishes regarding treatment preferences, including resuscitation and life-sustaining interventions, making it easier for healthcare providers to follow them.
Health Care Proxy: Similar to a durable power of attorney, a health care proxy allows an individual to appoint someone to make healthcare decisions on their behalf when they are unable to do so.
Mental Health Declaration: This document allows individuals to express their wishes regarding mental health treatment and designate someone to make decisions related to their mental health care when they cannot do so.
Declaration of Guardian in the Event of Later Incapacity: This document designates a guardian for an individual should they become incapacitated, ensuring that their care aligns with their preferences.

Each of these documents serves a vital role in ensuring that healthcare preferences are respected and upheld, providing peace of mind to individuals and their families during difficult times.

Dos and Don'ts

When filling out the California Advanced Health Care Directive form, attention to detail is essential. This document allows individuals to express their health care preferences and designate an agent to make decisions on their behalf if they become unable to do so. Here are some important considerations:

Do ensure you understand the contents of the form. Read through each section carefully to grasp what you are agreeing to, especially regarding your health care wishes.
Do involve your loved ones in the conversation. Discuss your preferences with family members or close friends. Their understanding of your wishes can provide comfort and clarity.
Do sign and date the document in the presence of witnesses. This step is crucial for the validity of your directive. Choose unbiased witnesses who are not named as your health care agents.
Don't rush the process. Take your time to consider your choices and reflect on your values. Rushed decisions may lead to future conflicts or misunderstandings.

Don't leave the form incomplete. Ensure that all necessary sections are filled out correctly. Incomplete documents can cause delays or complications in realizing your wishes.
Don't forget to provide copies to your agent and healthcare providers. Sharing the signed directive ensures that everyone involved is informed of your health care preferences.
Don't assume that verbal instructions are enough. Written directives have legal backing, whereas spoken wishes may not be honored if there is no documentation.
Don't neglect to review and update your directive periodically. As your life circumstances change, so may your health care preferences. Regular updates can prevent confusion later on.

Misconceptions

It is only for old people. Many believe that an advanced health care directive is only necessary for seniors. In reality, anyone over 18 can and should consider having one. Accidents and unexpected health issues can occur at any age.
It covers financial decisions. Some think that the directive includes instructions for financial matters. However, it specifically focuses on medical decisions and does not address financial affairs.
It's a legally binding will. An advanced health care directive is not a will. A will deals with the distribution of assets after death, while the directive outlines preferences for medical care during life.
It's only useful when a person is near death. This form can be important even before a person is near death. It allows individuals to communicate their wishes regarding treatment in a variety of health scenarios.
Once created, it cannot be changed. Many individuals believe that once the directive is completed, it cannot be altered. In fact, people have the right to update or revoke their directive at any time.
Health care providers are not obligated to follow it. This misconception suggests that health care professionals can ignore the directive. In truth, they are required to honor the specified wishes, as long as they are within legal limits.
Only doctors can make decisions. Some wrongly assume that only physicians make choices if a directive is in place. Patients and designated agents have significant authority and guidance over their medical treatment preferences.
Verbal instructions are sufficient. Relying solely on verbal instructions can lead to confusion. A written directive provides clear, documented instructions that health care professionals can follow.
It requires a lawyer to complete. While some may feel the need for legal assistance, the California Advanced Health Care Directive is user-friendly and can be filled out without a lawyer’s help.
It guarantees specific medical outcomes. Many have the misconception that having a directive ensures certain outcomes or treatments. However, it mainly serves to provide guidance based on personal values and choices rather than guaranteeing specific medical actions.

Key takeaways

When filling out and using the California Advanced Health Care Directive form, consider the following key takeaways:

Clear Instructions: Follow the instructions carefully to ensure your wishes are accurately reflected. Each section of the form has specific requirements.
Choosing Your Agent: Select a person you trust to make healthcare decisions on your behalf. They should understand your values and preferences regarding medical treatment.
Communicate Your Wishes: Discuss your decisions with family members and your chosen agent. Open conversations can help prevent confusion and ensure your wishes are honored.
Review Regularly: Revisit and update your directive as needed. Life changes, and your medical preferences may evolve over time.

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