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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.

(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 p

hone)

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 indiv

idual you choose as first alternate agent)

__________________________________________________________________________________________

(address) (city) (state) (ZIP Code)

__________________________________________________________________________________________

(home phone) (work phone)

OPTION

AL: 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) AG

ENT’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) AGE

NT’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) AGE

NT’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

INST

RUCTIONS FOR HEALTH CARE

If you f

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

(2.1) EN

D-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) RELI

EF 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) OTH

ER 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

DONA

TION 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

PRIM

ARY PHYSICIAN (OPTIONAL)

__________________

________________________________________________________________________

(name of physician)

__________________________________________________________________________________________

(address) (city) (state) (ZIP Code)

__________________________________________________________________________________________

(phone)

OPTION

AL: 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) SIG

NATURE: Sign and date the form here:

__________________

____________________ ________________________________________

(date) (sign your name)

______________________________________ ________________________________________

(address) (print your name)

_____________________________________________________________________________________

(city) (state)

(5.3) ST

ATEMENT 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)

_______________________________________

(signature of witness)

_______________________________________

(date)

_____________________________________________

(city) (state)

_____________________________________________

(signature of witness)

_____________________________________________

(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)

PART 6

SPECI

AL 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.

________________________________________

(sign your name)

________________________________________

(print your name)

______________________________________

(date)

______________________________________

(address)

______________________________________

(city) (state)

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