The California Advanced Health Care Directive is a legal document that allows individuals to outline their healthcare preferences in case they become unable to communicate their wishes. This directive enables you to appoint someone to make medical decisions on your behalf and specify your treatment preferences. To ensure your wishes are honored, consider filling out the form by clicking the button below.
When it comes to planning for future medical care, the California Advanced Health Care Directive form serves as a vital tool for individuals seeking to express their wishes. This document allows you to designate a trusted person, known as an agent, to make healthcare decisions on your behalf if you become unable to communicate those choices yourself. Additionally, the form provides space for you to outline specific medical treatments you may want or wish to avoid, ensuring that your preferences are honored. It covers a range of scenarios, from life-sustaining treatments to end-of-life care, allowing for a personalized approach to your healthcare. By completing this directive, you not only empower your chosen agent but also relieve your loved ones from the burden of making difficult decisions during emotionally challenging times. Understanding the nuances of this form can lead to peace of mind, knowing that your healthcare preferences will be respected, no matter what the future holds.
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 your healthcare wishes are known and respected. This process involves several key steps that will guide you through filling out the necessary information clearly and accurately.
After completing the form, ensure that it is stored in a safe yet accessible place. It is advisable to discuss your wishes with your healthcare agent and loved ones to promote understanding and clarity about your healthcare preferences.
A California Advanced Health Care Directive is a legal document that allows you to outline your preferences for medical treatment in case you become unable to communicate those wishes yourself. It combines two key components: a health care power of attorney and a living will. This directive ensures that your healthcare decisions are respected and that your chosen representative can make choices on your behalf.
Any adult who is at least 18 years old and of sound mind can create an Advanced Health Care Directive in California. This includes individuals who want to specify their medical care preferences or appoint someone to make decisions for them if they are incapacitated. It is advisable to discuss your wishes with your family and healthcare providers before completing the document.
When filling out your Advanced Health Care Directive, consider including the following:
Being clear about your wishes can help guide your agent and healthcare providers in making decisions that align with your values.
To appoint a health care agent, you need to clearly designate this person in your Advanced Health Care Directive. This individual should be someone you trust to make healthcare decisions on your behalf. It is important to have a conversation with your chosen agent about your preferences and values. Once you have selected your agent, include their name and contact information in the document. You should also have them sign the directive to acknowledge their role.
No, you do not need a lawyer to create an Advanced Health Care Directive in California. The form is designed to be user-friendly and accessible. However, if you have complex medical situations or family dynamics, consulting with a lawyer or a legal expert can provide additional guidance. Regardless, it’s essential that the directive is signed and witnessed according to California law to ensure its validity.
If you wish to change or revoke your Advanced Health Care Directive, you can do so at any time as long as you are of sound mind. To revoke the directive, simply destroy the original document and notify your healthcare agent and family members. If you want to make changes, you can create a new directive that clearly states the updates. Ensure that the new directive is signed and witnessed to be legally binding.
Not discussing their wishes with loved ones. It’s crucial to have conversations about your healthcare preferences with family and friends. This ensures everyone understands your choices.
Failing to choose an appropriate agent. Selecting someone who understands your values and will advocate for your wishes is essential. A trusted friend or family member is often a good choice.
Leaving sections blank. Every part of the form is important. If you skip sections, it can lead to confusion or misinterpretation of your wishes.
Not being specific enough about medical preferences. Vague instructions can lead to decisions that may not align with your true desires. Be clear about your choices.
Using outdated forms. Always make sure you have the most current version of the California Advanced Health Care Directive. Laws and regulations can change.
Not signing and dating the document. A signature is required for the directive to be valid. Without it, your wishes may not be honored.
Overlooking witness requirements. California law requires that your directive be signed in the presence of either a notary or witnesses. Failing to meet these requirements can invalidate the document.
Neglecting to review the directive periodically. Life changes, and so might your healthcare preferences. Regularly reviewing and updating your directive is important.
Assuming the directive will be automatically honored. It’s important to ensure that your healthcare providers and loved ones are aware of your directive. Share copies with them.
The California Advanced Health Care Directive is a crucial document that allows individuals to express their medical treatment preferences and appoint someone to make health care decisions on their behalf if they become unable to do so. This form is often used alongside other important documents that further clarify an individual's wishes regarding health care and estate matters. Below are five other forms and documents commonly associated with the California Advanced Health Care Directive.
Each of these documents plays a vital role in ensuring that an individual's health care preferences and estate plans are respected and followed. It is important to consider these forms carefully and to discuss them with loved ones and professionals to ensure that one's wishes are clearly understood and documented.
The California Advanced Health Care Directive (AHCD) is similar to the Durable Power of Attorney for Health Care. Both documents allow individuals to appoint someone to make health care decisions on their behalf if they become unable to do so. This ensures that a trusted person can advocate for the individual’s wishes regarding medical treatment, thus providing peace of mind during challenging times. While the AHCD also includes specific instructions about medical preferences, the Durable Power of Attorney focuses primarily on appointing a decision-maker.
Another document that shares similarities with the AHCD is the Living Will. A Living Will outlines an individual’s preferences regarding end-of-life care and specific medical treatments. Like the AHCD, it serves to communicate one’s wishes in situations where they cannot express them. However, the Living Will is often more limited in scope, as it primarily addresses life-sustaining treatments rather than appointing a person to make decisions.
The Do Not Resuscitate (DNR) order is also akin to the AHCD. A DNR is a specific medical order that instructs healthcare providers not to perform CPR if a person stops breathing or their heart stops. While the AHCD encompasses broader health care decisions and preferences, the DNR is focused solely on resuscitation efforts. Both documents aim to ensure that an individual’s wishes regarding medical interventions are respected.
The Medical Power of Attorney (MPOA) is another document that parallels the AHCD. The MPOA allows individuals to designate someone to make health care decisions on their behalf, similar to the Durable Power of Attorney for Health Care. However, the MPOA is often used in conjunction with other documents, like the AHCD, to provide a comprehensive approach to health care decision-making. It empowers a trusted person to act in the best interest of the individual when they are unable to do so.
The Physician Orders for Life-Sustaining Treatment (POLST) form is also related to the AHCD. The POLST is a medical order that translates an individual’s preferences regarding treatment into actionable orders for healthcare providers. While the AHCD allows for broader decision-making and appoints a representative, the POLST is specific to medical treatment preferences and is often used for individuals with serious health conditions. Both documents aim to ensure that medical care aligns with the individual’s values and wishes.
Another document similar to the AHCD is the Advance Directive for Mental Health Care. This document allows individuals to outline their preferences for mental health treatment and designate a decision-maker in case they are unable to communicate their wishes. While the AHCD primarily addresses physical health care, the Advance Directive for Mental Health Care focuses on mental health decisions, ensuring comprehensive coverage of an individual’s health care preferences.
Lastly, the Health Care Proxy is comparable to the California Advanced Health Care Directive. A Health Care Proxy allows individuals to appoint someone to make medical decisions on their behalf, similar to the Durable Power of Attorney for Health Care. While the terminology may differ from state to state, the underlying purpose remains the same: to ensure that someone trusted can make health care choices that reflect the individual’s values and preferences when they are unable to do so themselves.
When filling out the California Advanced Health Care Directive form, it's important to approach the task with care. Here are some essential do's and don'ts to keep in mind:
By following these guidelines, you can ensure that your Advanced Health Care Directive accurately reflects your preferences and is legally binding.
The California Advanced Health Care Directive is an important legal document that allows individuals to outline their medical preferences and appoint someone to make healthcare decisions on their behalf if they are unable to do so. However, there are several misconceptions surrounding this directive. Here are seven common misunderstandings:
Understanding these misconceptions can help individuals make informed decisions about their healthcare preferences and ensure that their wishes are respected.
The California Advanced Health Care Directive form is an important tool for individuals to express their healthcare preferences. Here are some key takeaways to consider when filling it out and using it:
By taking these steps, you can ensure that your healthcare preferences are respected and that your loved ones are prepared to make informed decisions on your behalf.
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