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In California, the Advanced Health Care Directive is a crucial legal document that empowers individuals to express their healthcare preferences in the event they become unable to communicate those wishes themselves. This form serves two primary functions: it allows you to appoint a trusted person, known as an agent, to make medical decisions on your behalf, and it enables you to outline specific instructions regarding your medical treatment. By completing this directive, you can ensure that your values and desires are respected, even when you cannot voice them. The document covers a wide range of topics, including preferences for life-sustaining treatments, pain management, and organ donation. Additionally, it provides clarity on your wishes regarding artificial nutrition and hydration, which can be critical in end-of-life situations. Understanding the significance of this form can provide peace of mind, knowing that your healthcare decisions will align with your personal beliefs and desires, regardless of the circumstances you may face in the future.

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Steps to Using California Advanced Health Care Directive

Filling out the California Advanced Health Care Directive form is an important step in planning for your future health care needs. It allows you to express your wishes regarding medical treatment and appoint someone to make decisions on your behalf if you are unable to do so. Here’s a straightforward guide to help you complete the form effectively.

  1. Begin by downloading the California Advanced Health Care Directive form from a reliable source or obtain a physical copy from your healthcare provider.
  2. Read through the entire form carefully to understand what information is required.
  3. In the first section, fill in your personal information, including your name, address, and date of birth.
  4. Next, designate your health care agent. This is the person you trust to make medical decisions for you if you cannot communicate your wishes.
  5. Clearly outline any specific instructions regarding your health care preferences. Be as detailed as possible to ensure your wishes are understood.
  6. If you have any additional preferences, such as organ donation or end-of-life care, include them in the designated section.
  7. After completing the form, sign and date it in the appropriate section. Ensure that you are doing this in the presence of a witness.
  8. Have your witness sign the form as well. Remember, the witness cannot be your health care agent or a family member.
  9. Consider having the form notarized for added validity, although this is not always required.
  10. Make copies of the completed form and distribute them to your health care agent, family members, and your doctor.

After you have filled out and signed the form, it’s essential to keep it in a safe place while ensuring that the people involved in your care are aware of its existence and contents. Regularly review and update your directive as your preferences or circumstances change.

Key takeaways

The California Advanced Health Care Directive form is an essential tool for individuals seeking to express their medical preferences and appoint someone to make health care decisions on their behalf. Understanding its significance and proper usage can greatly enhance the effectiveness of this directive. Here are nine key takeaways:

  • Personal Autonomy: The directive empowers individuals to maintain control over their medical treatment, even when they can no longer communicate their wishes.
  • Two Components: This form consists of two main parts: the appointment of an agent and the declaration of health care preferences.
  • Choosing an Agent: Selecting a trusted person as your health care agent is crucial. This individual will make decisions based on your values and preferences.
  • Specific Instructions: Clearly articulate your wishes regarding medical treatments, life support, and other health care decisions to guide your agent effectively.
  • Legal Validity: The form must be signed and dated in front of a witness or notarized to ensure it is legally binding in California.
  • Regular Updates: Life circumstances change. Regularly review and update your directive to reflect your current wishes and relationships.
  • Communication: Discuss your health care preferences with your agent and family members to ensure everyone understands your wishes.
  • Access to Medical Records: Grant your agent access to your medical records, enabling them to make informed decisions on your behalf.
  • State-Specific: Remember, this directive is specific to California. If you move to another state, familiarize yourself with that state’s laws regarding health care directives.

By understanding these key aspects, individuals can navigate the complexities of health care decisions more confidently, ensuring their wishes are honored even in challenging circumstances.

Misconceptions

Many individuals have misconceptions about the California Advanced Health Care Directive form. Understanding these misunderstandings can help ensure that people make informed decisions regarding their health care preferences. Below are six common misconceptions:

  • It is only for the elderly or terminally ill. Many believe that only those who are elderly or facing terminal illnesses need an Advanced Health Care Directive. In reality, anyone over the age of 18 can benefit from having one, as unexpected medical situations can arise at any age.
  • It is a legally binding document. Some think that simply filling out the form makes it legally binding. While it does carry legal weight, it must be properly signed, witnessed, or notarized according to California law to be valid.
  • It only covers end-of-life decisions. A common misconception is that the directive only pertains to end-of-life care. In fact, it can address a wide range of medical decisions, including treatments for serious illnesses, surgeries, and preferences for pain management.
  • Once completed, it cannot be changed. Many assume that once they have filled out the directive, it is set in stone. However, individuals can update or revoke their directive at any time as long as they are mentally competent to do so.
  • It eliminates the need for family discussions. Some people believe that having a directive means they do not need to discuss their wishes with family. In truth, open communication with loved ones is essential to ensure that everyone understands and respects the individual's preferences.
  • Health care providers are required to follow it in all circumstances. There is a misconception that health care providers must adhere to the directive without exception. While they are generally obligated to follow the directive, there may be circumstances where medical professionals cannot comply due to legal or ethical considerations.

Clarifying these misconceptions can empower individuals to take control of their health care decisions, ensuring that their wishes are respected when they are unable to communicate them directly.

Preview - California Advanced Health Care Directive Form

ADVANCE HEALTH CARE DIRECTIVE FORM

 

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Probate Code - PROB

DIVISION 4.7. HEALTH CARE DECISIONS [4600 - 4806] ( Division 4.7 added by Stats. 1999, Ch. 658, Sec. 39. ) PART 2. UNIFORM HEALTH CARE DECISIONS ACT [4670 - 4743] ( Part 2 added by Stats. 1999, Ch. 658, Sec. 39. )

CHAPTER 2. Advance Health Care Directive Forms [4700 - 4701] ( Chapter 2 added by Stats. 1999, Ch. 658, Sec. 39. )

4701. The statutory advance health care directive form is as follows:

ADVANCE HEALTH CARE DIRECTIVE

(California Probate Code Section 4701)

Explanation

You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.

Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. (Your agent may not be an operator or employee of a community care facility or a residential care facility where you are receiving care, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker.)

Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to:

(a)Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition.

(b)Select or discharge health care providers and institutions.

(c)Approve or disapprove diagnostic tests, surgical procedures, and programs of medication.

(d)Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation.

(e)Donate your organs, tissues, and parts, authorize an autopsy, and direct disposition of remains.

Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out Part 2 of this form.

Part 3 of this form lets you express an intention to donate your bodily organs, tissues, and parts following your death.

Part 4 of this form lets you designate a physician to have primary responsibility for your health care.

After completing this form, sign and date the form at the end. The form must be signed by two qualified witnesses or acknowledged before a notary public. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care, and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility.

You have the right to revoke this advance health care directive or replace this form at any time.

ADVANCE HEALTH CARE DIRECTIVE FORM

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PART 1

POWER OF ATTORNEY FOR HEALTH CARE

(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me:

(name of individual you choose as agent)

(address)

(city)

(state)

(ZIP Code)

 

 

 

 

 

 

(home phone)

(work phone)

 

 

OPTIONAL: If I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health care decision for me, I designate as my first alternate agent:

(name of individual you choose as first alternate agent)

(address)

(city)

(state)

(ZIP Code)

 

 

 

 

 

 

(home phone)

(work phone)

 

 

OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or reasonably available to make a health care decision for me, I designate as my second alternate agent:

(name of individual you choose as second alternate agent)

(address)

(city)

(state)

(ZIP Code)

 

 

 

 

 

 

(home phone)

(work phone)

 

 

(1.2) AGENT'S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:

(Add additional sheets if needed.)

(1.3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box.

If I mark this box , my agent's authority to make health care decisions for me takes effect immediately.

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 3 of 7

(1.4.) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.

(1.5) AGENT'S POSTDEATH AUTHORITY: My agent is authorized to donate my organs, tissues, and parts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:

:

(Add additional sheets if needed.)

(1.6) NOMINATION OF CONSERVATOR: If a conservator of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not wiling, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated.

PART 2

INSTRUCTIONS FOR HEALTH CARE

If you fill out this part of the form, you may strike any wording you do not want.

(2.1) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:

(a) Choice Not to Prolong Life

I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR

(b) Choice to Prolong Life

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

(2.2) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:

(Add additional sheets if needed.)

(2.3) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:

(Add additional sheets if needed.)

 

ADVANCE HEALTH CARE DIRECTIVE FORM

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PART 3

 

 

DONATION OF ORGANS, TISSUES, AND PARTS AT DEATH

 

 

(OPTIONAL)

 

(3.1)

Upon my death, I give my organs, tissues, and parts (mark box to indicate yes).

 

By checking the box above, and notwithstanding my choice in Part 2 of this form, I authorize my agent to consent to any temporary medical procedure necessary solely to evaluate and/or maintain my organs, tissues, and/or parts for purposes of donation.

My donation is for the following purposes (strike any of the following you do not want):

(a)Transplant

(b)Therapy

(c)Research

(d)Education

If you want to restrict your donation of an organ, tissue, or part in some way, please state your restriction on the following lines:

If I leave this part blank, it is not a refusal to make a donation. My state-authorized donor registration should be followed, or, if none, my agent may make a donation upon my death. If no agent is named above, I acknowledge that California law permits an authorized individual to make such a decision on my behalf. (To state any limitation, preference, or instruction regarding donation, please use the lines above or in Section 1.5 of this form).

PART 4

PRIMARY PHYSICIAN

(OPTIONAL)

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

(name of physician)

(address)

(city)

(state)

(ZIP Code)

(phone)

OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician:

(name of physician)

(address)

(city)

(state)

(ZIP Code)

(phone)

ADVANCE HEALTH CARE DIRECTIVE FORM

PART 5

PAGE 5 of 7

(5.1) EFFECT OF COPY: A copy of this form has the same effect as the original.

(5.2) SIGNATURE: Sign and date the form here:

(date)

(sign your name)

(address)

(print your name)

(city) (state)

(5.3) STATEMENT OF WITNESSES: I declare under penalty of perjury under the laws of California (1) that the individual who signed or acknowledged this advance health care directive is personally known to me, or that the individual's identity was proven to me by convincing evidence (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not a person appointed as agent by this advance directive, and (5) that I am not the individual's health care provider, an employee of the individual's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly.

First witness

Second witness

(print name)

(address)

(city)(state)

(print name)

(address)

(city)(state)

(signature of witness)

(signature of witness)

(date)

(date)

(5.4) ADDITIONAL STATEMENT OF WITNESSES: At least one of the above witnesses must also sign the following declaration:

I further declare under penalty of perjury under the laws of California that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual's estate upon his or her death under a will now existing or by operation of law.

(signature of witness)

(signature of witness)

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 6 of 7

 

PART 6

SPECIAL WITNESS REQUIREMENT

(6.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the following statement:

STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN

I declare under penalty of perjury under the laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am serving as a witness as required by Section 4675 of the Probate Code.

(date)

(sign your name)

(address)

(print your name)

(city) (state)

 

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

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 7 of 7

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)

 

 

 

Document Specs

Fact Name Description
Purpose The California Advanced Health Care Directive allows individuals to specify their healthcare preferences and appoint an agent to make decisions on their behalf if they become unable to do so.
Governing Law This form is governed by California Probate Code Sections 4600-4800, which outline the legal framework for advanced healthcare directives in the state.
Agent Appointment Individuals can designate one or more agents to make medical decisions for them, ensuring that their wishes are respected even when they cannot communicate them.
Witness Requirements The directive must be signed by the individual and witnessed by at least two people, or notarized, to be legally valid.
Revocation Individuals have the right to revoke or change their directive at any time, as long as they are mentally competent to do so.
Healthcare Preferences The form allows individuals to outline specific preferences regarding medical treatments, including life-sustaining measures and palliative care options.