State Codes and Statutes

State Codes and Statutes

Statutes > California > Prob > 4700-4701

PROBATE CODE
SECTION 4700-4701



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)