Fill - CALIFORNIA Advance Directive Planning for Important Health Care

CALIFORNIA

Advance Directive

Planning for Important Health Care Decisions

CaringInfo

1731 King St., Suite 100, Alexandria, VA 22314

www.caringinfo.org

800/658-8898

CaringInfo, a program of the National Hospice and Palliative Care Organization (NHPCO),

is a national consumer engagement initiative to improve care at the end of life.

It’s About How You LIVE

is a national community engagement campaign encouraging

individuals to make informed decisions about end-of-life care and services. The campaign

encourages people to:

Learn about options for end-of-life services and care

Implement plans to ensure wishes are honored

Voice decisions to family, friends and health care providers

Engage in personal or community efforts to improve end-of-life care

Note: The following is not a substitute for legal advice. While CaringInfo updates the

following information and form to keep them up-to-date, changes in the underlying law

can affect how the form will operate in the event you lose the ability to make decisions for

yourself. If you have any questions about how the form will help ensure your wishes are

carried out, or if your wishes do not seem to fit with the form, you may wish to talk to

your health care provider or an attorney with experience in drafting advance directives.

Reproduction and distribution by an organization or organized group without the written permission of the

National Hospice and Palliative Care Organization is expressly forbidden.

Using these Materials

BEFORE YOU BEGIN

1. Check to be sure that you have the materials for each state in which you may receive

health care.

2. These materials include:

• Instructions for preparing your advance directive, please read all the

instructions.

• Your state-specific advance directive forms, which are the pages with the gray

instruction bar on the left side.

ACTION STEPS

1. You may want to photocopy or print a second set of these forms before you start so

you will have a clean copy if you need to start over.

2. When you begin to fill out the forms, refer to the gray instruction bars — they will

guide you through the process.

3. Talk with your family, friends, and physicians about your advance directive. Be sure

the person you appoint to make decisions on your behalf understands your wishes.

4. Once the form is completed and signed, photocopy the form and give it to the person

you have appointed to make decisions on your behalf, your family, friends, health care

providers and/or faith leaders so that the form is available in the event of an

emergency.

5. California maintains an Advance Directive Registry. By filing your advance directive

with the registry, your health care provider and loved ones may be able to find a copy

of your directive in the event you are unable to provide one. You can read more about

the registry, including instructions on how to file your advance directive, at

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

6. You may also want to save a copy of your form in an online personal health records

application, program, or service that allows you to share your medical documents with

your physicians, family, and others who you want to take an active role in your

advance care planning.

INTRODUCTION TO YOUR CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

This packet contains a legal document, a California Advance Health Care Directive,

that protects your right to refuse medical treatment you do not want, or to request

treatment you do want, in the event you lose the ability to make decisions yourself. You

may complete any or all of the first four parts, depending on your advance planning

needs. You must complete part 5.

Part 1 is a Power of Attorney for Health Care. This part lets you name someone (an

agent) to make decisions about your health care. Unless otherwise written in your

advance directive, your power of attorney for health care becomes effective when your

primary doctor determines that you lack the ability to understand the nature and

consequences of your health care decisions or the ability to make and communicate your

health care decisions. If you want your agent to make health care decisions for you now,

even though you are still capable of making health care decisions, you can include this

instruction in your power of attorney for health care designation.

Part 2 includes your Individual Instructions. This is your state’s living will. It lets you

state your wishes about health care in the event that you can no longer speak for yourself

and you may limit the individual instructions to take effect only if a specified condition

arises.

Part 3 allows you to express your wishes regarding organ donation.

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

health care.

Part 5 contains the signature and witnessing provisions so that your document will be

effective.

This form does not expressly address mental illness. If you would like to make advance

care plans regarding mental illness, you should talk to your physician and an attorney

about an advance directive tailored to your needs.

Note: These documents will be legally binding only if the person completing them is a

competent adult, who is 18 years of age or older, or an emancipated minor.

INSTRUCTIONS FOR YOUR CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

How do I make my advance health care directive legal?

You must sign and date your advance directive or direct an adult to do so for you if you

are unable to sign it yourself.

You r signature must be witnessed by or you must acknowledge your signature before a

notary public or two adult witnesses. Your two adult witnesses may not be

• your health care provider or an employee of your health care provider,

• the operator or an employee of a community care facility,

• the operator or an employee of a residential care facility for the elderly, or

• the person you have appointed as an agent, if you have appointed an agent.

In addition, one of your witnesses must be unrelated to you by blood, marriage, or

adoption and not entitled to any portion of your estate.

If you are a patient in a skilled nursing facility when you execute your advance directive,

one of your witnesses must be a patient advocate or ombudsman.

Whom should I appoint as my agent?

Your agent is the person you appoint to make decisions about your health care if you

become unable to make those decisions yourself. Your agent may be a family member or a

close friend whom you trust to make serious decisions. The person you name as your

agent should clearly understand your wishes and be willing to accept the responsibility of

making health care decisions for you.

Your agent cannot be

• your supervising health care provider,

• the operator of a community care facility or residential care facility where you

are receiving care, or

• the employee of a health care institution where you are receiving care or

employee of a community care facility or residential care facility where you are

receiving care, unless:

o the employee is related to you by blood, marriage, or adoption,

o the employee is your registered domestic partner, or

o the employee is your coworker at the facility or institution.

If you have a conservator appointed for you as part of involuntary commitment

proceedings under the Lanterman-Petris-Short Act, that conservator cannot be appointed

as your agent unless you are represented by a lawyer who signs a certificate stating that

you have been advised of your rights. If this applies to you, you should talk with your

lawyer about your rights, the applicable law, and the potential consequences involved.

On the other hand, you may include in your advance directive a nomination for the

individual appointed as your conservator, if necessary. The court will consider your

nomination in any protective proceeding.

You can appoint a second and third person as your alternate agents. An alternate agent

will step in if the person(s) you name as agent is/are unable, unwilling or unavailable to

act for you.

Should I add personal instructions to my advance directive?

One of the strongest reasons for naming an agent is to have someone who can respond

flexibly as your medical situation changes and deal with situations that you did not foresee.

If you add instructions to this document it may help your agent carry out your wishes, but

be careful that you do not unintentionally restrict your agent’s power to act in your best

interest. In any event, be sure to talk with your agent about your future health care and

describe what you consider to be an acceptable “quality of life.”

What if I change my mind?

Except for the appointment of your agent, you may revoke any portion or this entire

advance directive at any time and in any way that communicates your intent to revoke.

This could be by telling your agent or physician that you revoke, by signing a revocation,

or simply by tearing up your advance directive.

In order to revoke your agent’s appointment, you must either tell your supervising health

care provider of your intent to revoke or revoke your agent’s appointment in a signed

writing.

If you execute a new advance directive, it will revoke the old advance directive to the

extent of any conflict between the two documents.

Unless you specify otherwise in Part 2, if you designate your spouse as your agent, that

designation will automatically be revoked by divorce or annulment of your marriage.

What other important facts should I know?

Your agent, if you appoint one, does not have authority to authorize convulsive treatment,

psychosurgery, sterilization, or abortion, or to have you committed or placed in a mental

health treatment facility.

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE - PAGE 1 OF 13

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 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 an employee of the

health care institution where you are receiving care, unless your agent is

related to you, is your registered domestic partner, or is a co-worker. Your

supervising health care provider can never act as your agent.)

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;

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; and

(e) Donate your organs, tissues and parts, authorize an autopsy,

and direct the disposition of your remains.

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE - PAGE 2 OF 13

Explanation Continued

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 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 in Part 5. 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 and alternate agent(s) 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.

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE — PAGE 3 OF 13

PART 1: POWER OF ATTORNEY FOR HEALTH CARE

(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)

INSTRUCTIONS

PRINT THE NAME,

HOME ADDRESS

AND HOME AND

WORK TELEPHONE

NUMBERS OF YOUR

PRIMARY

AGENT

RINT THE NAME,

HOME ADDRESS

AND HOME AND

WORK TELEPHONE

NUMBERS OF YOUR

FIRST ALTERNATE

AGENT

(OPTIONAL)

PRINT THE NAME,

HOME ADDRESS

AND HOME AND

WORK TELEPHONE

NUMBERS OF YOUR

SECOND

ALTERNATE

AGENT

(OPTIONAL)

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE — PAGE 4 OF 13

(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.)

(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.

(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.

(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, in paragraph (2) above, or in Part 3 of

this form:

____________________________________________________________

(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.

ADD

STRUCTIONS

HERE ONLY IF YOU

WANT TO LIMIT

THE POWER OF

YOUR AGENT

INITIA

L THE BOX IF

YOU WISH YOUR

AGENT’S

AUTHORITY TO

BECOME EFFECTIVE

IMMEDIATELY

CRO

SS OUT AND

INITIAL ANY

STATEMENTS IN

PARAGRAPHS 4, 5,

OR 6 THAT DO NOT

REFLECT YOUR

WISHES

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE — PAGE 5 OF 13

PART 2: INSTRUCTIONS FOR HEALTH CARE

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

want.

(7) 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: (Initial only one box)

[ ] (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,

[ ] (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.

(8) RELIEF FROM PAIN: Except as I state in the following space, I direct

that treatment for alleviation of pain or discomfort should be provided at all

times even if it hastens my death:

____________________________________________________________

ITIAL THE

PARAGRAPH

THAT BEST

REFLECTS YOUR

WISHES

REGARDING

LIFE-SUPPORT

MEASURES

DD INSTRUCTIONS

HERE ONLY IF YOU

WANT TO LIMIT

PAIN RELIEF OR

COMFORT CARE

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE — PAGE 6 OF 13

(9) 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.)

ADD OTHER

INSTRUCTIONS, IF

ANY, REGARDING

YOUR ADVANCE

CARE PLANS

THESE

INSTRUCTIONS CAN

FURTHER ADDRESS

YOUR HEALTH CARE

PLANS, SUCH AS

YOUR WISHES

REGARDING

HOSPICE

TREATMENT, BUT

CAN ALSO ADDRESS

OTHER ADVANCE

PLANNING ISSUES,

SUCH AS YOUR

BURIAL WISHES

ATTACH

ADDITIONAL PAGES

IF NEEDED

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE — PAGE 7 OF 13

PART 3: DONATION OF ORGANS AT DEATH

(OPTIONAL)

(10) Upon my death (initial applicable box):

[ ] (a) I do not give any of my organs, tissues, or parts and do

not want my agent, conservator, or family to make a

donation on my behalf,

[ ] (b) I give any needed organs, tissues, or parts,

[ ] (c) I give the following organs, tissues, or parts only

My donation is for the following purposes:

(strike any of the following you do not want)

(1) Transplant

(2) Therapy

(3) Research

(4) Education

By checking the box above to give any organs, tissues or parts, or to give

specified organs, tissues or parts only, 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.

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.

GAN

DONATION

(OPTIONAL)

ITIAL THE BOX

THAT AGREES

WITH YOUR

WISHES ABOUT

ORGAN

DONATION

STRIKE

THROUGH ANY

USES YOU DO

NOT AGREE TO

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE — PAGE 8 OF 13

PART 4: PRIMARY PHYSICIAN

(OPTIONAL)

(11) 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)

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

RINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBER OF YOUR

PRIMARY

PHYSICIAN

(OPTIONAL)

RINT THE NAME,

ADDRESS AND

TELEPHONE

NUMBER OF YOUR

ALTERNATE

PRIMARY

PHYSICIAN

(OPTIONAL)

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE - PAGE 9 OF 13

PART 5: EXECUTION

This Health Care Directive will not be valid unless it is EITHER:

(A) Signed by two (2) qualified adult witnesses who are personally

known to you or to whom you have proven your identity by convincing

evidence and who are present when you sign or acknowledge your

signature. Your witnesses may not be

• your health care provider or an employee of your health care

provider,

• the operator or an employee of a community care facility,

• the operator or an employee of a residential care facility for the

elderly, or

• the person you have appointed as an agent, if you have

appointed an agent.

In addition, one of your witnesses must be unrelated to you by blood,

marriage, or adoption and not entitled to any portion of your estate. (Use

Alternative 1, below, if you decide to have your signature witnessed.)

(B) Witnessed by a notary. (Use Alternative 2, below (page 12), if you

decide to have your signature notarized.)

If you are a patient in a skilled nursing facility when you execute your

advance directive, one of your witnesses must be a patient advocate or

ombudsman. This witness must sign the statement on page 13, even if you

have had your advance directive notarized.

F YOU CHOOSE TO

SIGN WITH

WITNESSES, USE

ALTERNATIVE 1,

BELOW

F YOU CHOOSE TO

HAVE YOUR

SIGNATURE

NOTARIZED, USE

ALTERNATIVE 2,

BELOW (PAGE 12)

HERE ARE SPECIAL

WITNESSING

REQUIREMENTS IF

YOU LIVE IN A

SKILLED NURSING

FACILITY

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE - PAGE 10 OF 13

OPTION 1: Sign before a Witness

_______________________ ___________________________________

(date) (sign your name)

__________________________________________________________

(print your name)

__________________________________________________________

(address)

__________________________________________________________

(city) (state) (zip code)

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 an 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:

__________________________ _______________________________

(date) (signature of witness)

__________________________________________________________

(printed name of witness)

__________________________________________________________

(address)

__________________________________________________________

(city) (state) (zip code)

Second Witness:

______________________ ____________________________________

(date) (signature of witness)

__________________________________________________________

(printed name of witness)

__________________________________________________________

(address)

__________________________________________________________

(city) (state) (zip code)

SIGN AND DATE

THE DOCUMENT

AND THEN PRINT

YOUR NAME AND

ADDRESS

WITNESSING

PROCEDURE

BOTH OF YOUR

WITNESSES MUST

AGREE WITH THIS

STATEMENT

ONE WITNESS

MUST ALSO SIGN

THE STATEMENT

ON PAGE 11

HAVE YOUR

WITNESSES SIGN

AND DATE THE

DOCUMENT AND

THEN PRINT THEIR

NAME AND

ADDRESS

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE - PAGE 11 OF 13

ADDITIONAL WITNESS STATEMENT

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.

__________________________ ________________________________

(date) (signature of witness)

ONE OF YOUR

WITNESSES MUST

ALSO SIGN THIS

STATEMENT

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CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE - PAGE 12 OF 13

>>>

SIGN AND DATE

THE DOCUMENT

AND THEN PRINT

YOUR NAME AND

ADDRESS

A NOTARY PUBLIC

MUST FILL OUT

THIS PORTION OF

THE FORM

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ACKNOWLEDGMENT

State of California

County of ___________________)

On __________________________ before me,________________________________

(insert name and title of the 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)

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.

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE - PAGE 13 OF 13

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 witness as required by section 4675 of the

Probate Code.

__________________________ ________________________________

(date) (signature)

__________________________________________________________

(printed name)

__________________________________________________________

(address)

__________________________________________________________

(city) (state) (zip code)

Courtesy of CaringInfo

1731 King St., Suite 100, Alexandria, VA 22314

www.caringinfo.org, 800/658-8898

THIS SECTION

MUST BE

COMPLETED

BY A PATIENT

ADVOCATE OR

OMBUDSMAN IF

YOU ARE A

RESIDENT IN A

SKILLED NURSING

FACILITY

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You Have Filled Out Your Health Care Directive, Now What?

1. Your

California Advance Health Care Directive

is an important legal document. Keep

the original signed document in a secure but accessible place. Do not put the

original document in a safe deposit box or any other security box that would keep

others from having access to it.

2. Give photocopies of the signed original to your agent and alternate agent,

doctor(s), family, close friends, clergy, and anyone else who might become involved

in your health care. If you enter a nursing home or hospital, have photocopies of

your document placed in your medical records.

3. Be sure to talk to your agent(s), doctor(s), clergy, family, and friends about your

wishes concerning medical treatment. Discuss your wishes with them often,

particularly if your medical condition changes.

4. California maintains an Advance Directive Registry. By filing your advance directive

with the registry, your health care provider and loved ones may be able to find a

copy of your directive in the event you are unable to provide one. You can read

more about the registry, including instructions on how to file your advance directive,

at http://www.sos.ca.gov/registries/advance-health-care-directive-registry/

5. You may also want to save a copy of your form in an online personal health records

application, program, or service that allows you to share your medical documents

with your physicians, family, and others who you want to take an active role in your

advance care planning.

6. If you want to make changes to your documents after they have been signed and

witnessed, you must complete a new document.

7. Remember, you can always revoke your California document.

8. Be aware that your California document will not be effective in the event of a

medical emergency. Ambulance and hospital emergency department personnel are

required to provide cardiopulmonary resuscitation (CPR) unless they are given a

separate directive that states otherwise. These directives called “prehospital medical

care directives” or “do not resuscitate orders” are designed for people whose poor

health gives them little chance of benefiting from CPR. These directives instruct

ambulance and hospital emergency personnel not to attempt CPR if your heart or

breathing should stop.

Currently not all states have laws authorizing these orders. We suggest you speak to

your physician if you are interested in obtaining one. CaringInfo does not

distribute these forms.

OR donate online today: www.NationalHospiceFoundation.org/donate

Congratulations!

You’ve downloaded your free, state specific advance directive.

You are taking important steps to make sure your wishes are known. Please consider helping us

keep this resource free.

Your generous support to the National Hospice Foundation allows us to continue to provide FREE

resources, tools, and information to educate and empower individuals to access advance care

planning, caregiving, hospice and grief services.

Please show your support for our mission and consider making a tax-deductible gift

to the National Hospice Foundation today.

Since 1992, the National Hospice Foundation has been dedicated to creating FREE resources for

individuals and families facing a life-limiting illness, raising awareness for the need for hospice

and palliative care, and providing ongoing professional education and skills development to

hospice and palliative care professionals across the nation. To learn more, please visit

www.NationalHospiceFoundation.org

You may wonder if a gift of $35, $50 or $100 to the National Hospice Foundation would make a

difference, but it is only because of the generosity of others like you that these FREE resources

are made available.

Please consider supporting our mission by returning a generous tax-deductible donation.

Every gift makes a difference! Your gift strengthens the Foundation’s ability to provide FREE

caregiver and family resources.

Cut along the dotted line and use the coupon below to return a check contribution of

the most generous amount you can send. Thank you.

YES! I want to support the important work of the National Hospice Foundation.

$35

helps us provide webinars to hospice professionals

$50

helps us provide free advance directives

$100 helps us maintain our free InfoLine

$________ to support the mission of the National Hospice Foundation.

Return to:

National Hospice Foundation

PO Box 824401

Philadelphia, PA 19182-4401

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CALIFORNIA Advance Directive Planning for Important Health Care

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