Fill - Free fillable Advance-healthcare-directive-booklet Advance Healthcare Directive

Advance Healthcare Directive

An easy-to-use form to make your goals, values and preferences known

Why should you have an

Advance Healthcare Directive?

It is important to plan ahead and clearly state your healthcare goals, values and

preferences. An Advance Healthcare Directive is the best place to do this. Your

completed directive will give you and those close to you greater peace of mind.

The process of ﬁlling out your directive may also help you talk with loved ones

about what matters most to you.

There also is a number of resources available at Cedars-Sinai to help you complete

your directive, including social workers, spiritual care experts and a free Advance

Care Planning class. For information on these and other resources, please see the

back cover of this document.

What should you do after you

have completed your

Advance Healthcare Directive?

1. Have your directive notarized or signed by two eligible witnesses.

• Option 1: Sign the document in the presence of a notary public.

• Option 2: Have two eligible witnesses sign the document.

2. Share copies with:

• Your healthcare agent(s)

• Your loved ones

• Your main physician

• Your lawyer

3. Make sure it is uploaded into your electronic medical record, using one of the

following options:

Upload to

My CS-Link™

Website:

mycslink.org

Use the Advance

Healthcare Directive

page listed

under Resources.

Please include your

name and date of birth

on the ﬁrst page.

Fax Number:

310-248-8078

Please include your

name and date of birth

on the ﬁrst page.

Mailing Address:

Health Information

Department

8700 Beverly Blvd.

South Tower, Room 2901

Los Angeles, CA

90048

Please include your

name and date of birth

on the ﬁrst page.

Email Address:

groupMNSHID@cshs.org

Please include your

name and date of birth

on the ﬁrst page.

Email an

electronic copy

to Cedars-Sinai

Mail to

Cedars-Sinai

Fax to

Cedars-Sinai

4. Keep the original copy in a safe (but accessible) place.

1

PART 1:

My Healthcare Agent

• Section A: Choosing My Healthcare Agent 2

• Section B: When Would I Like My Healthcare Agent 3

to Begin Representing Me?

PART 2:

My Healthcare Goals, Values and Preferences

• Section A: Quality of Life 4

• Section B: Scope of Tretment 5

• Section C: Further Explanation (Optional) 6

PART 3 (OPTIONAL):

Additional Preferences:

Organ Donation

My Wishes for After I Die

7

PART 4:

How Strictly Do I Want My

Advance Healthcare Directive Followed?

8

PART 5 (OPTIONAL):

Identifying My Physician 9

PART 6:

Signing My Advance Healthcare Directive 11 – 15

Extra Pages

16–17

Additional Resources Back Cover

Table of Contents

2

My Name: ___________________________________________________________

My Date of Birth: ___________________________________________________

PART 1:

My Healthcare Agent

SECTION A CHOOSING MY HEALTHCARE AGENT

n For help with ﬁlling out this section, please refer to Part 1 Section A of the

Step-by-Step Guide (Pages 3-4).

I choose the following person to speak on my behalf if at any time I am not able

to (or choose not to) express my own goals, values and preferences:

Healthcare Agent’s Name: _______________________________________________

Relationship to You: _____________________________________________________

Phone Number(s): _______________________________________________________

Email Address (if known): ________________________________________________

The following person(s) can serve as alternate agents (this is optional):

First Alternate

Alternate Agent’s Name: _________________________________________________

Relationship to You: _____________________________________________________

Phone Number(s): _______________________________________________________

Email Address (if known): ________________________________________________

Second Alternate

Alternate Agent’s Name: _________________________________________________

Relationship to You: _____________________________________________________

Phone Number(s): _______________________________________________________

Email Address (if known): ________________________________________________

3

Part 1 (continued)

SECTION B

WHEN WOULD I LIKE MY HEALTHCARE AGENT

TO BEGIN REPRESENTING ME?

For help with ﬁlling out this section, please refer to Part 1 Section B of the

Step-by-Step Guide (Page 5).

I would like my healthcare agent to begin participating in decision-making

about my healthcare at the following time:

Please complete the sentence above by initialing either option 1 or option 2:

Option 1

When my physician determines that I am unable to express my own goals,

v

alues and preferences.

___________________

(Initial Here)

OR

Option 2

From this time forward, even if I am still able to speak for myself.

___________________

(Initial Here)

4

If you would like to share additional details, please use any of the lined spaces provided on

page 6 or at the end of this document.

PART 2:

My Healthcare Goals, Values and Preferences

SECTION A QUALITY OF LIFE

n For help with ﬁlling out this section, please refer to Part 2 Section A of the

Step-by-Step Guide (Pages 6-9).

My life would be worth living, and therefore I would want my life to be

prolonged as long as possible, under the following circumstances:

Please complete the sentence above by selecting option 1, 2 or 3:

Option 1



All circumstances—even if it means only the basic functioning of my organs

(heart, lungs, kidneys, etc.) with or without machines.

OR

Option 2



All circumstances, unless I would NEVER recover the ability to (please ﬁll in

the space below):

Physical and Bodily Considerations (e.g., live without being permanently

connected to mechanical life support, get out of bed, go outside):

___________________________________________________________________________________

Cognitive Considerations (e.g., be awake, be conscious, be able to think clearly):

___________________________________________________________________________________

Interactive, Social and Community Considerations (e.g., communicate in

some way with other people, live outside of a healthcare facility):

___________________________________________________________________________________

OR

Option 3



I am not sure.

5

If you would like to share additional details, please use any of the lined spaces provided on

page 6 or at the end of this document.

Part 2 (continued)

SECTION B SCOPE OF TREATMENT

n For help with ﬁlling out this section, please refer to Part 2 Section B of the

Step-by-Step Guide (Pages 10-11).

If my physician believes that I have a reasonable chance of recovering to the

quality of life I stated on page 4, I would be willing to undergo the following:

Please complete the sentence above by selecting option 1, 2 or 3:

Option 1



All procedures, treatments and interventions oered by my healthcare team.

OR

Option 2



All procedures, treatments and interventions oered by my healthcare team, EXCEPT:

___________________________________________________________________________________

OR

Option 3



I am not sure.

6

If you would like to share additional details, please use any of the lined spaces provided at the

end of this document.

Part 2 (continued)

SECTION C FURTHER EXPLANATION (OPTIONAL)

If you would like to share more thoughts and information, you may do so here. This is a good

place to mention any cultural or religious views that inﬂuence your healthcare goals, values

and preferences.

_________________________________________________________________________________________

7

If you would like to share additional details, please use any of the lined spaces provided at the

end of this document.

PART 3 (OPTIONAL):

Additional Preferences

For help with ﬁlling out this section, please refer to Part 3 of the

Step-by-Step Guide (Page 12).

Organ Donation



 I wish to donate any and all organs and tissues.

OR



 I do not wish to donate any of my organs or tissues.

OR



 I wish to donate only the following organs or tissues (please specify):

____________________________________________________________________________________________________________

My Wishes for After I Die

I have the following wishes regarding funeral, burial and/or cremation arrangements:

_________________________________________________________________________________________

8

PART 4:

How Strictly Do I Want My Advance

Healthcare Directive Followed?

For help with ﬁlling out this section, please refer to Part 4 of the

Step-by-Step Guide (Page 13).

I want my goals, values and preferences as written in this directive to:

Please complete the sentence above by initialing either option 1 or option 2:

Option 1

Serve as a general guide, based on what I know now.

___________________

(Initial Here)

OR

Option 2

Be followed strictly, under all circumstances.

___________________

(Initial Here)

If you would like to share more thoughts and information, please use the space

bel

ow:

_________________________________________________________________________________________

If you would like to share additional details, please use any of the lined spaces provided at the

end of this document.

9

PART 5 (OPTIONAL):

Identifying My Physician

For help with ﬁlling out this section, please refer to Part 5 of the

Step-by-Step Guide (Page 14).

You may have physicians involved in your care who understand your goals, values and

preferences

. If you would like them to be involved in discussions regarding your condition

and treatment options, please list their names and contact information below.

Name of Physician: _____________________________________________________________________

Phone Number(s) (if known): ___________________________________________________________

Email Address (if known): ______________________________________________________________

Name of Physician: _____________________________________________________________________

Phone Number(s) (if known): ___________________________________________________________

Email Address (if known): ______________________________________________________________

Name of Physician: _____________________________________________________________________

Phone Number(s) (if known): ___________________________________________________________

Email Address (if known): ______________________________________________________________

Please remember also to discuss your values and choices with the physician(s) named above

and provide him/her/them a copy of your directive.

10

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11

PART 6:

Signing My Advance Healthcare Directive

For help with ﬁlling out this section, please refer to Part 6 of the

Step-by-Step Guide (Page 15).

In order to make this document legal and valid, you must sign below

in the presence of EITHER a notary public (Page 13) OR two

witnesses (Page 14):

Name (Print):

_________________________________________________________________________________________

Signature:

_________________________________________________________________________________________

Date of Signature:

_________________________________________________________________________________________

12

This page left intentionally blank

13

Signing My Advance Healthcare Directive

With a Notary

Note: If you complete the section below, you do not need to complete Page 14.

NOTARIZATION

(California All-Purpose Acknowledgment, Civil Code 1189)

A notary public or other ocer 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, ____________________________________________________________

Date Here Insert Name and Title of the Ocer

personally appeared _____________________________________________________________________

Name(s) of Signer(s)

_________________________________________________________________________________________

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 _______________________________________________________________________________

Signature of Notary Public

Place Notary Seal Above

14

Signing My Advance Healthcare Directive

With Witnesses

Note: If you complete the section below, you do not need to complete Page 13.

STATEMENT OF WITNESSES

I declare under penalty of perjury under the laws of California 1) that the individual who signed

or acknowledged this Advance Healthcare 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 Healthcare 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 Healthcare Directive; and 5) that I am not the individual’s

healthcare provider, an employee of an operator of a community care facility, nor the employee

of an operator of a residential care facility for the elderly; and 6) I am over 18 years of age.

WITNESS #1

________________________________________________________________________________________

Signature

of Witness #1 Date

________________________________________________________________________________________

Printed Name of Witness #1 Phone Number

WITNESS #2

________________________________________________________________________________________

Signature

of Witness #2 Date

________________________________________________________________________________________

Printed Name of Witness #2 Phone Number

One of the witnesses also must sign the following declaration:

I further declare under penalty of perjury under the laws of California that I am not related

to the individual ex

ecuting this Advance Healthcare 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 #1 or #2 Date

________________________________________________________________________________________

Printed Name of Witness #1 or #2 Date

15

Special Witness Requirement

Note: For nursing home or skilled nursing facility patients only, a signature

from a patient advocate or ombudsman is required in addition to completing

either Page 13 or Page 14.

If you are not a nursing home patient or skilled nursing facility patient, you may skip

this section.

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.

________________________________________________________________________________________

Signature of Patient Advocate or Ombudsman Date

________________________________________________________________________________________

Printed Name of Patient Advocate or Ombudsman Phone Number

16

Extra pages

_________________________________________________________________________________________

17

_________________________________________________________________________________________

Additional Resources

To sign up for the free Advance Care Planning Class, call 800-700-6424.

Cedars-Sinai Supportive Care Medicine, 310-423-9520

Cedars-Sinai’s Supportive Care Medicine (SCM) team helps inpatients and outpatients who are

facing life-limiting or advanced illness to achieve the best possible quality of life, and also provides

support for families. SCM clinicians are experts in managing a full range of symptoms, both physical

and psychological; they are also speciﬁcally trained to help with Advance Care Planning and

Advance Healthcare Directives.

Cedars-Sinai Spiritual Care, 310-423-5550; cedars-sinai.org/spiritualcare

Members of the Cedars-Sinai Spiritual Care Department oer spiritual care services to

Cedars-Sinai patients and their loved ones. Chaplains are available to visit patients and help

work through dicult issues related to end-of-life decisions and care.

Cedars-Sinai Center for Healthcare Ethics, 310-423-9636; cedars-sinai.org/ethics

For patients hospitalized at Cedars-Sinai, the center oers clinical ethics consultation. The

aim is to help patients, family members, physicians and other members of the patient care team

examine and discuss pertinent ethical values and goals.

Cedars-Sinai Social Work

Inpatient: 310-423-4446 | Outpatient: 310-248-8311

The following are websites that provide information on advance

healthcare planning:

• Advance Health Care Directive Registry—California:

sos.ca.gov/registries/advance-health-care-directive-registry

• Aging With Dignity: agingwithdignity.org

• American Hospital Association: putitinwriting.org

• California Medical Association: cmanet.org

• Caring Connections: caringinfo.org

• Coalition for Compassionate Care of California: coalitionccc.org and capolst.org

(POLST forms in English and other languages)

• Hospice Association of America: hospice.nahc.org

• Donate Life California—Organ and Tissue Donor Registry: donatelifecalifornia.org

• U.S. Department of Veterans Aairs: losangeles.va.gov/patients/advance.asp

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