4700. The form provided in Section 4701 may, but need not, be used
to create an advance health care directive. The other sections of
this division govern the effect of the form or any other writing used
to create an advance health care directive. An individual may
complete or modify all or any part of the form in Section 4701.
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) Make anatomical gifts, 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 and tissues 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.
* * * * * * * * * * * * * * * *
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.
(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 make anatomical gifts, 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 willing, 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.)
PART
3
DONATION OF ORGANS AT
DEATH
(OPTIONAL)
(3.1) Upon my death (mark applicable box):
( ) (a) I give any needed organs, tissues, or
parts, OR
( ) (b) I give the following organs, tissues, or
parts only.
____________________________________________________
(c) My gift is for the following purposes (strike
any of the following you do not want):
(1) Transplant
(2) Therapy
(3) Research
(4) Education
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)
* * * * * * * * * * * * * * * *
PART 5
(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) (print name)
___________________________ ________________________
(address) (address)
___________________________ ________________________
(city) (state) (city) (state)
___________________________ ________________________
(signature of (signature of
witness) 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 (signature of
witness) witness)
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)
4700. The form provided in Section 4701 may, but need not, be used
to create an advance health care directive. The other sections of
this division govern the effect of the form or any other writing used
to create an advance health care directive. An individual may
complete or modify all or any part of the form in Section 4701.
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) Make anatomical gifts, 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 and tissues 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.
* * * * * * * * * * * * * * * *
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.
(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 make anatomical gifts, 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 willing, 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.)
PART
3
DONATION OF ORGANS AT
DEATH
(OPTIONAL)
(3.1) Upon my death (mark applicable box):
( ) (a) I give any needed organs, tissues, or
parts, OR
( ) (b) I give the following organs, tissues, or
parts only.
____________________________________________________
(c) My gift is for the following purposes (strike
any of the following you do not want):
(1) Transplant
(2) Therapy
(3) Research
(4) Education
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)
* * * * * * * * * * * * * * * *
PART 5
(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) (print name)
___________________________ ________________________
(address) (address)
___________________________ ________________________
(city) (state) (city) (state)
___________________________ ________________________
(signature of (signature of
witness) 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 (signature of
witness) witness)
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)
4700. The form provided in Section 4701 may, but need not, be used
to create an advance health care directive. The other sections of
this division govern the effect of the form or any other writing used
to create an advance health care directive. An individual may
complete or modify all or any part of the form in Section 4701.
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) Make anatomical gifts, 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 and tissues 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.
* * * * * * * * * * * * * * * *
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.
(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 make anatomical gifts, 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 willing, 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.)
PART
3
DONATION OF ORGANS AT
DEATH
(OPTIONAL)
(3.1) Upon my death (mark applicable box):
( ) (a) I give any needed organs, tissues, or
parts, OR
( ) (b) I give the following organs, tissues, or
parts only.
____________________________________________________
(c) My gift is for the following purposes (strike
any of the following you do not want):
(1) Transplant
(2) Therapy
(3) Research
(4) Education
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)
* * * * * * * * * * * * * * * *
PART 5
(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) (print name)
___________________________ ________________________
(address) (address)
___________________________ ________________________
(city) (state) (city) (state)
___________________________ ________________________
(signature of (signature of
witness) 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 (signature of
witness) witness)
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)
