Advance Health Care Directive
LIFE CARE planning
my values, my choices, my care
kp.org/lifecareplan
REMEMBER
1
Have this document
witnessed or notarized
2
Sign and date
3
Return a copy to
Kaiser Permanente
1
Full name:
Medical Record #:
Introduction
This Advance Health Care Directive allows you to share your values, your choices, and your instructions
about your health care. This form may be used to:
Name someone you trust to make health care decisions for you (your “health care agent”), OR
Provide written instructions about your health care, OR
Both name a health care agent AND provide written instructions for health care.
Part 1 allows you to name a health care agent.
Part 2 gives you an opportunity to share your values and what is important to you.
Part 3 allows you to give written instructions about your health care.
Part 4 allows you to guide your agent’s decision making by stating your hopes and wishes.
Part 5 allows you to make your Advance Health Care Directive legally valid in the State of California.
Part 6 prepares you to share your wishes and this document with others.
Youarefreetocompleteormodifyalloranypartofthisform,oruseadierentform.
This Advance Health Care Directive will replace any Advance Health Care Directive you have completed
inthepast,totheextentthattheydier.Ifyouwanttocancelorchangeyournamedagent,completea
new document or inform your health care provider in person.
Full name:
Medical Record number:
Date of birth:
Mailing address:
Home phone:
Cell phone:
Work phone: Email:
Document type: Advance Directive Description: Advance Directive Signed On
2
Full name:
Medical Record #:
Part 1. My Health Care Agent
Selecting a health care agent:
Choose someone who knows you well, who you trust to honor your views and values, and who is able to
make dicult decisions in st
ressful situations. Once you have selected your health care agent, take the
time to discuss your views and treatment goals with that
per
son and make sure they are willing to act as
your decision maker.
IfIamunabletocommunicatemywishesandhealthcaredecisions,orifmyhealthcareproviderhas
determinedthatIamnotabletomakemyownhealthcaredecisions,Ichoosethefollowingperson(s)to
make my health care decisions.
*
My health care agent must make health care decisions that are consistent with my instructions in this
document, if any, and other wishes known by my agent. Otherwise, my agent must make health care
decisions that he or she believes to be in my best interest, considering what he or she knows about my
personal values.
Thisformdoesnotgivemyhealthcareagenttheauthoritytomakenancialorotherbusiness
decisions. My health care agent does not have the power to place me in a mental health treatment
facility or consent to some types of mental health treatments.
My primary (main) health care agent is:
Full name: Relationship to me:
Home phone: Cell phone:
Work phone: Email:
Mailing address:
*
Iunderstandthatmyhealthcareagentcannotbemysupervisinghealthcareprovideroranoperatorofa
communityorresidentialcarefacilitywhereIamreceivingcare.Myagentalsomaynotbeanemployeeofa
communitycare,residentialcare,orhealthcarefacilitywhereIamreceivingcare,unlessthatpersonismy
relative by blood, marriage, or adoption, is my registered domestic partner, or is my co-worker.
Need additional assistance?
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Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
IfIcancelmyprimaryhealthcareagent’sauthority,orifmyprimaryagentisnotwilling,able,or
reasonablyavailabletomakeahealthcaredecisionforme,Inametheindividualbelowasmyrst
alternate agent.
First alternate health care agent:
Full name: Relationship to me:
Home phone: Cell phone:
Work phone: Email:
Mailing address:
IfIcancelmyagentsauthority,primaryorrstalternate,orifneitheriswilling,able,orreasonably
availabletomakeahealthcaredecisionforme,Inametheindividualbelowasmysecondalternate
agent.
Second alternate health care agent:
Full name: Relationship to me:
Home phone:
Cell phone:
Work phone: Email:
Mailing address:
Powers of my health care agent:
Unless I limit my agent’s authority, my health care agent has all of the following powers:
A. Make choices for me about my health care. This includes decisions about tests, medicine,
andsurgery.Italsoincludesdecisionstoprovide,notprovide,orstopallformsofhealth
caretokeepmealive,includingarticialnutrition(food),hydration(water),andcardiopulmonary
resuscitation.
B. Decide which physicians, health providers, and organizations provide my medical treatment.
C. Arrange for and make decisions about the care of my body after death (including autopsy and
organ donation).
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Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Please provide any additional comments or restrictions to your agent’s authority here. (For example,
you may name people you would not want involved in medical decisions on your behalf. You may also
specify decisions you would not want your agent to make.) Attach additional page(s) if necessary.
Additional health care agent instructions:
Check the box or boxes below, if you want your agent to follow these instructions.
❏Iwantmyagenttocontinueasmyhealthcareagentevenifadissolution,annulment,or
termination of our marriage or domestic partnership has been completed.
❏IwantmyagenttoimmediatelybeginmakinghealthcaredecisionsformeevenifIam
able to decide or speak for myself.
Need additional assistance?
kp.org/lifecareplan
4
Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Part 2. My Values and Beliefs
Iwantmyagentandlovedonestoknowwhatmattersmosttome,sothattheycanmakedecisions
aboutmyhealthcarethatmatchwhoIamandwhatisimportanttome.
Togiveyouasenseofwhatmattersmosttome,I’dliketotellyousomethingsaboutmyself,suchas
howIenjoyspendingmytime,whoIliketobewith,andwhatIliketodo.I’dalsoliketotellyouabout
the circumstances that would make life no longer worthwhile for me.
1. If I were having a good day, I would be doing the following:
2. What matters most to me is:
3. Life would no longer be worth living if I were not able to:
4. Religious or spiritual traditions:
Iamofthe faith, and am a member of (faith/spiritual community)
in (city) ,
(phone #) .IwouldlikemyagenttonotifythemifIamseriouslyill
ordying.Iwouldliketoincludeinmyfuneral,ifpossible,thefollowing(people,music,rituals,etc.):
Ihavenospecicreligiousorspiritualtraditions.
Document type: Advance Directive Description: Advance Directive Signed On
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Full name:
Medical Record #:
Part 3. My Health Care Instructions
If you choose not to provide written instructions, your health care agent will make decisions based on
your spoken directions. If your directions are unknown, your agent will make decisions based on what
he or she believes is in your best interest, considering your values.
In the situation below, we ask you to consider a sudden unexpected event that leaves you unable to
communicate for yourself.
Iaskthatmyhealthcareagentrepresentmychoicesasdetailedbelow,andthatmydoctorsandhealth
careteamhonorthem.Ifmyhealthcareagentoralternateagentsarenotavailableorareunableto
make decisions on my behalf, this document represents my wishes.
1. Treatments to prolong life
Consider the following situation:
You have a sudden accident or stroke.
Doctorshavedeterminedyouhaveabraininjury,leavingyouunabletorecognizeyourselforyour
loved ones. The doctors have told your agent and/or family that you are not expected to recover
these abilities. Life-sustaining treatments, such as a ventilator (i.e., breathing machine), or a feed-
ingtube,arerequiredtokeepyoualive.Inthissituationwhatwouldyouwant?
I would want to be kept comfortable and:
IwouldwanttoSTOPlife-sustainingtreatment.Irealizethiswouldprobablyleadmeto
diesoonerthanifIweretocontinuetreatment.
Iwouldwanttocontinuelife-sustainingtreatments.
Please provide any additional instructions about life-sustaining treatments. For example, you may want
to state a specic time peri
od that you would want to be kept alive if there were no improvement to your
health.
Choose
One
Document type: Advance Directive Description: Advance Directive Signed On
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Full name:
Medical Record #:
2. CPR (Cardiopulmonary resuscitation)
CPRisanattempttobringyoubacktolifewhenyourheartandbreathinghavestopped.It
may include chest compressions (forceful pushing on the chest to make the heart contract),
medicines, electrical shocks, and a breathing tube.
YouhaveachoiceaboutCPR.CPRcansavelives.Itisnotaseectiveasmostpeoplethink.
CPR works best if done quickly, within a few minutes, on a healthy adult. When CPR is
performed, it can result in broken ribs, punctured lungs, or brain damage from lack of oxygen.*
IfyouwouldlikeadditionalinformationaboutCPR,pleaserequestthe brochure called CPR:
Cardiopulmonary Resuscitation
IfyoudonotwantCPR,pleasediscusswithyourphysicianotherdocumentsyoumaywant
to complete.
In the event that your heart and breathing stop, what would you want?
IalwayswantCPRattempted.
IneverwantCPRattempted,butratherwanttopermitanaturaldeath.
IwantCPRattemptedunlessthedoctortreatingmedeterminesanyofthefollowing:
• Ihaveanincurableillnessorinjuryandamdying;or
• Ihavenoreasonablechanceofsurvivalifmyheartorbreathingstops;or
• Ihavelittlechanceofsurvivalifmyheartorbreathingstopsandtheprocessof
resuscitationwouldcausesignicantsuering.
Choose
One
* Research shows that if you are in a hospital and get CPR, you have a 22 percent chance of surviving and leaving the
hospitalalive.SaketGirotra,M.D.,BrahmajeeK.Nallamothu,M.D.,M.P.H.,JohnA.Spertus,M.D.,M.P.H.,etal.“Trendsin
SurvivalafterIn-HospitalCardiacArrest;”New England Journal of Medicine367;20November15,2012.
Need additional assistance?
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Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Part 4. My Hopes and Wishes (Optional)
1. As I’m nearing my death, I want my loved ones to know I would appreciate having the
following (prayers, rituals, music) and where I prefer to die:
2. Other wishes/instructions:
3. Organ donation(Ifyouhavenopreference,youragentmaydecideforyou.):
Upon my death, I want to donate my eyes, tissues, and any organs. My specic wishes
(if any) are:
Upon my death, I only wish to donate the following organs, tissues, or body parts:
I DO NOT want to donate my eyes, tissues, and/or organs.
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Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Part 4. My Hopes and Wishes (Optional)
4 . If you wish to donate your body for research, arrangements must be made in advance:
Organization/Institution Name: Phone:
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Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Part 5. Making This Document Legally Valid
To make your Advance Health Care Directive legally valid in California, it must be signed by two
witnesses, OR acknowledged before a Notary Public. Follow the steps outlined below in the order in
which they are listed:
1. Choose EITHER
Two Witnesses OR Notary Public
• One of your witnesses
cannot be related to you (by
blood, marriage, or adoption)
and cannot be entitled to
any part of your estate.
• Your primary and alternate
agents cannot sign as
witnesses.
• When you are with
your witnesses, sign or
acknowledge your signature.
• Witnesses will sign on
page
11.
• Youwillsignonpage12.
• Do NOT sign this document
unless you are with a Notary
Public.
• Notary Public will sign
on
page12.(Skippage11.)
• Youwillsignonpage12.
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Document type: Advance Directive Description: Advance Directive Signed On
Special Witness Requirement
Ifyouareapatientinaskillednursingfacility,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anombudsmanasdesignatedbytheStateDepartmentofAgingandthatIamserving
asawitnessasrequiredbySection4675oftheCaliforniaProbateCode.
Signature:
Date:
Full name:
Medical Record #:
This form must be signed by two witnesses (only one of whom can be related to you), OR
acknowledged before a Notary Public. If using a Notary Public, skip this page.
Statement of Witnesses
STATEMENT OF WITNESSES:IdeclareunderpenaltyofperjuryunderthelawsofCalifornia
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,
thattheindividualsignedoracknowledgedthisAdvanceHealthCareDirectiveinmypresence,
thattheindividualappearstobeofsoundmindandundernoduress,fraud,orundueinuence,
thatIamnotappointedasanagentbythisAdvanceHealthCareDirective,and
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, or an employee of an
operator of a residential care facility for the elderly.
Witness Number One:
Print full name:
Address:
Signature: Date:
Witness Number Two:
Print full name:
Address:
Signature: Date:
ADDITIONAL STATEMENT OF WITNESS: At least one of the witnesses must meet the following
requirements and 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.
Print full name: Signature:
Date:
1
1
11
Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Notary Public
State of California
County of
on before me, ,
Date NameandTitleofOcer
personally appeared
Name of Signer
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ocialseal.
Signature
(Seal)
SIGNATURE
My name printed:
My Signature: Date:
Ifyouarephysicallyunabletosign,anymarkyoumakethatyouintendtobeyoursignature
is acceptable.
Anotarypublicorotherocercompletingthiscerticateveriesonlytheidentityofthe
individualwhosignedthedocumenttowhichthiscerticateisattached,andnotthe
truthfulness, accuracy, or validity of that document.
2
1
12
Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Part 6. Next Steps
Now that you have completed your Advance Health Care Directive, you should also take the following steps.
Discuss:
Review your health care wishes with the person you have asked to be your agent (if you haven’t
alreadydoneso).Makesureheorshefeelsabletoperformthisimportantjobforyouinthefuture.
Talk to the rest of your family and close friends who might be involved if you have a serious illness
orinjury.Makesuretheyknowwhoyourhealthcareagentis,andwhatyourwishesare.
Give copies:
Give your health care agent a copy of your Advance Health Care Directive.
Bring a copy of your Advance Health Care Directive to your next scheduled appointment
- OR -
Send in your copy by mail to:
 KaiserPermanenteCentralScanning,1011S.EastStreet,Anaheim,CA92805
- OR -
Via email: SCALCentralized-Scanning-Center@kp.org
Make a copy for yourself and keep it where it can be easily found.
Take with you:
Ifyougotoahospitalornursinghome,takeacopyofyourAdvanceHealthCareDirectiveand
ask that it be placed in your medical record.
Take a copy with you any time you will be away from home for an extended period of time.
Review regularly:
Review your health care wishes whenever any of the “Five D’s” occur:
Decadewhen you start each new decade of your life.
Death—whenever you experience the death of a loved one.
Divorce—whenyouexperienceadivorceorothermajorfamilychange.
Diagnosiswhen you are diagnosed with a serious health condition.
Declinewhenyouexperienceasignicantdeclineordeteriorationofanexistinghealth
condition, especially when you are unable to live on your own.
Changing your Advance Health Care Directive:
Ifyourwishesorhealthcareagentchange,pleasenotifyyourproviderorlloutanewAdvanceHealth
Care Directive. Tell your agent, your family, and anyone else who has a copy, and provide a copy to
KaiserPermanente.
13
Document type: Advance Directive Description: Advance Directive Signed On
Full name:
Medical Record #:
Copies of this document have been given to:
•Primary(Main)HealthCareAgent
Full name:
Telephone:
•AlternateHealthCareAgent#1
Full name:
Telephone:
•AlternateHealthCareAgent#2
Full name:
Telephone:
•HealthCareProvider/Clinic
Name:
Telephone:
•Others:
Name:
Telephone:
Bring a copy of your Advance Health Care Directive to your next scheduled appointment
- OR -
Sendinyourcopybymailto:KaiserPermanenteCentralScanning
1011S.EastStreet
Anaheim,
CA92805
- OR -
Via email: SCALCentralized-Scanning-Center@kp.org
3
14
Document type: Advance Directive Description: Advance Directive Signed On
Need additional assistance?
kp.org/lifecareplan
This information is not intended to diagnose health problems or to take the place of medical advice or care you receive from your
physician or other health care professional. If you have persistent health problems, or if you have additional questions, please
consult with your doctor.
Adapted with permission from copyrighted material of The Permanente Medical Group, Inc., Northern California.
©2019 Southern California Permanente Medical Group. All rights reserved.
Center for Healthy Living
CHL032e (3/19)
kp.org
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