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In California, the Advanced Health Care Directive is a vital document that empowers individuals to make their healthcare preferences known in advance. This form allows you to designate a trusted person, often referred to as a healthcare agent, to make medical decisions on your behalf if you become unable to communicate those wishes yourself. It also provides a platform to outline specific medical treatments you would or would not want, addressing critical situations such as end-of-life care and life-sustaining measures. By completing this directive, you ensure that your values and desires regarding healthcare are respected, even when you cannot voice them. This document not only clarifies your preferences but also alleviates the burden on family members who might otherwise struggle with difficult decisions during emotional times. Understanding the components of the California Advanced Health Care Directive is essential for anyone looking to take control of their medical future.
Key takeaways
Here are some important points to consider when filling out and using the California Advanced Health Care Directive form:
- Clearly outline your medical preferences. Specify the types of medical treatments you would or would not want in different situations.
- Designate a health care agent. Choose someone you trust to make decisions on your behalf if you are unable to do so.
- Discuss your wishes with your agent. Ensure they understand your values and preferences regarding health care.
- Keep the document accessible. Store the completed directive in a place where it can be easily found, and share copies with your health care agent and family members.
- Review and update regularly. Life circumstances change, so it is important to revisit your directive periodically to ensure it still reflects your wishes.
- Understand the legal requirements. Make sure to follow California’s guidelines for signing and witnessing the document to ensure its validity.
Dos and Don'ts
When filling out the California Advanced Health Care Directive form, it is important to follow certain guidelines to ensure your wishes are clearly communicated. Here are some dos and don'ts to keep in mind:
- Do clearly identify your health care agent, someone you trust to make decisions on your behalf.
- Do discuss your wishes with your health care agent to ensure they understand your preferences.
- Do complete the form in its entirety to avoid any confusion about your wishes.
- Do sign and date the form in the presence of a notary public or witnesses, as required by law.
- Don't use vague language. Be specific about your wishes regarding medical treatment.
- Don't forget to provide copies of the completed directive to your health care agent and family members.
- Don't assume that verbal instructions are enough. Written documentation is crucial.
Documents used along the form
The California Advanced Health Care Directive is an important document that outlines your healthcare preferences and appoints someone to make decisions on your behalf if you become unable to do so. Alongside this directive, there are several other forms and documents that can help ensure your wishes are honored. Here are some commonly used forms that complement the Advanced Health Care Directive.
- Durable Power of Attorney for Health Care: This document allows you to designate someone to make healthcare decisions for you if you are unable to communicate your wishes. It is often used in conjunction with the Advanced Health Care Directive.
- Do Not Resuscitate (DNR) Order: A DNR order instructs medical personnel not to perform CPR if your heart stops or if you stop breathing. This document is crucial for those who wish to avoid aggressive life-saving measures.
- Living Will: A living will details your preferences regarding medical treatment in situations where you cannot express your wishes. It typically addresses end-of-life care and other critical health decisions.
- Articles of Incorporation: This essential legal document, which can be sourced from Fast PDF Templates, outlines the company's fundamental details like its name and purpose, and is vital for establishing a corporation in New York.
- Physician Orders for Life-Sustaining Treatment (POLST): This form translates your wishes regarding life-sustaining treatment into actionable medical orders. It is especially important for those with serious health conditions.
- Organ Donation Registration: This document allows you to express your wishes regarding organ donation after death. It can be included in your Advanced Health Care Directive or registered separately.
- Healthcare Proxy: Similar to the Durable Power of Attorney for Health Care, a healthcare proxy specifically appoints an individual to make medical decisions on your behalf. This ensures that someone you trust will be there to advocate for your preferences.
Understanding these forms can help you create a comprehensive plan for your healthcare decisions. By preparing these documents, you ensure that your wishes are respected and that your loved ones are clear on how to act on your behalf in critical situations.
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Things to Know About This Form
What is a California Advanced Health Care Directive?
A 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 you trust to make medical decisions on your behalf and specify your wishes regarding medical treatment, including life-sustaining measures.
Who can create an Advanced Health Care Directive?
Any adult who is at least 18 years old and is of sound mind can create an Advanced Health Care Directive in California. This means you must be able to understand the information related to your healthcare and make decisions based on that information.
What should I include in my Advanced Health Care Directive?
Your Advanced Health Care Directive should include the following:
- Your healthcare preferences, such as your wishes regarding life support, resuscitation, and pain management.
- The name of the person you appoint as your healthcare agent, who will make decisions for you if you cannot.
- Any specific instructions you want your healthcare agent to follow.
- Information about organ donation if you wish to include that.
How do I ensure my Advanced Health Care Directive is valid?
To make sure your Advanced Health Care Directive is valid in California, follow these steps:
- Complete the form accurately, ensuring all necessary sections are filled out.
- Sign the document in the presence of a notary public or two witnesses who are not related to you and will not benefit from your estate.
- Keep copies of the directive for yourself, your healthcare agent, and your medical providers.
Can I change or revoke my Advanced Health Care Directive?
Yes, you can change or revoke your Advanced Health Care Directive at any time, as long as you are of sound mind. To do this, you should create a new directive or write a statement that clearly indicates your intent to revoke the previous one. Make sure to inform your healthcare agent and any healthcare providers of the changes.
Preview - California Advanced 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
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) |
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(home phone) |
(work phone) |
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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) |
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(home phone) |
(work phone) |
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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) |
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(home phone) |
(work phone) |
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(1.2) AGENT'S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold, or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:
(Add additional sheets if needed.)
(1.3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box.
If I mark this box 
, my agent's authority to make health care decisions for me takes effect immediately.
ADVANCE HEALTH CARE DIRECTIVE FORM
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(1.4.) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.
(1.5) AGENT'S POSTDEATH AUTHORITY: My agent is authorized to donate my organs, tissues, and parts, authorize an autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:
:
(Add additional sheets if needed.)
(1.6) NOMINATION OF CONSERVATOR: If a conservator of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not wiling, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated.
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you fill out this part of the form, you may strike any wording you do not want.
(2.1)
(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.)
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PART 3 |
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DONATION OF ORGANS, TISSUES, AND PARTS AT DEATH |
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(3.1) |
Upon my death, I give my organs, tissues, and parts (mark box to indicate yes). |
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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
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
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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) |
(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) |
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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
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) |
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(Amended by Stats. 2018, Ch. 287, Sec. 1. (AB 3211) Effective January 1, 2019.)
ADVANCE HEALTH CARE DIRECTIVE FORM
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ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California,
County of
On |
before me, |
(insert name and title of officer)
personally appeared
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person
(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature |
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(SEAL) |
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Document Specifics
| Fact Name | Description |
|---|---|
| Purpose | The California Advanced Health Care Directive form allows individuals to outline their healthcare preferences and appoint a person to make medical decisions on their behalf if they become unable to do so. |
| Governing Law | This directive is governed by the California Probate Code, specifically Sections 4600-4806. |
| Eligibility | Any adult, 18 years or older, can complete an Advanced Health Care Directive in California. |
| Witness Requirements | The form must be signed by the individual and witnessed by two adults, or notarized, to be legally valid. |
| Revocation | Individuals can revoke their directive at any time, as long as they are of sound mind. This can be done verbally or in writing. |
| Storage | It is recommended to keep the completed directive in a safe place and share copies with family members, healthcare providers, and the appointed agent. |
How to Fill Out California Advanced Health Care Directive
Completing the California Advanced Health Care Directive form is an important step in ensuring your healthcare preferences are honored. After filling out the form, you will need to sign it in the presence of a witness or a notary public to make it legally binding. Follow these steps carefully to ensure everything is completed correctly.
- Begin by downloading the California Advanced Health Care Directive form from a reliable source.
- Fill in your name and contact information at the top of the form.
- Designate a healthcare agent. This person will make medical decisions on your behalf if you are unable to do so.
- Clearly outline your wishes regarding medical treatment. Be specific about the types of care you would or would not want.
- Consider including preferences for end-of-life care, such as whether you want life support or resuscitation.
- Sign and date the form in the designated area. This step is crucial for legality.
- Have your signature witnessed by at least one adult who is not related to you and does not stand to inherit from you. Alternatively, you can have the form notarized.
- Make copies of the completed form. Distribute these copies to your healthcare agent, family members, and your medical provider.
By following these steps, you will ensure that your healthcare preferences are documented and can be easily accessed when needed. Taking the time to complete this form is a responsible decision that can provide peace of mind for both you and your loved ones.