Fillable Scal Advance Directive En 102021 (Kaiser Permanente)

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Scal Advance Directive En 102021 (Kaiser Permanente)

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  • 28 check-boxes
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Advance
Health Care
Directive
State of California
Life Care Planning:
Values, Choices, Care
kp.org/lifecareplan
Be sure to complete this document by:
1. Signing and dating where needed.
2. Having it witnessed or notarized.
Your health care agent (decision maker)
cannot sign as a witness.
3. Remember to return a copy to Kaiser
Permanente and give a copy to your
health care agent. You keep the
original form.
Advance Health Care Directive
What is an
Advance Health
Care Directive?
The Advance Health Care Directive (AHCD) is a legal document that
provides your health care teams with guidance about what to do in the
event you are not able to make health care decisions for yourself.
The AHCD allows you to:
• Choose a health care agent (decision maker) to make health care decisions
on your behalf if you are unable to do so AND/OR
• Express your values, beliefs, and health care preferences
The AHCD provides guidance to both your health care agent (decision maker)
and health care team in developing a treatment plan for you. It does NOT
tell emergency personnel what treatments you want during a medical
emergency.
You can update ANY of your preferences in your AHCD at any time by
completing a new document. This new AHCD will replace any AHCD you have
completed in the past.
Why is an
AHCD important?
You have the right to share your preferences about your own health care.
This document provides guidelines to your health care agent (decision maker) and
doctors to provide care that is right for you.
It is also an opportunity to reect on what quality of life means to you, and how
your preferences may impact your loved ones. By completing this document
while you are able and talking about it with your loved ones, it may help
reduce confusion and disagreement about what you may or may not want.
Who is the
AHCD for?
Any adult over the age of 18 of sound mind should consider completing an
Advance Health Care Directive regardless of their health status.
Other references:
page 1
Life Care Planning:
Values, Choices, Care
kp.org/lifecareplan
Full Name:
Medical Record #:
What is in
this document?
You can ll out
as much or
as little
of this
document as you
would like.
If you decide to
not complete a
section, simply
draw a line
through the page
and initial it. This
will let us know it
was intentionally
left blank.
Part 5 is
required for this
document to be
legal in the State
of Califor
nia.
The Kaiser Permanente Advance Health Care Directive (AHCD) contains
ve parts, including how to make it a legal document:
Part 1: Choosing My Health Care Agent(s) (Decision Makers)
Allows you to name someone to make health care decisions on your behalf if you
are unable to make them for yourself.
Part 2: My Values & Beliefs
Gives you an opportunity to reect on what quality of life and living well mean to
you. We encourage you to complete this section as it will help you think through the
rest of the document.
Part 3: Choosing My Health Care Preferences
Allows you to document your preferences for health care if you are unable to make
your own health care decisions, due to an injury or illness.
Part 4: After-Death Preferences
Allows you to communicate any after-death wishes you may have including organ
donation, funeral wishes, etc.
Part 5: Making It Legal
Completing this section makes this document legal in the State of California.
This document also includes a checklist to help you share your preferences with
Kaiser Permanente and others.
This Advance Health
Care Directive
belongs to:
Full name
Medical Record number Date of birth
Mailing address
City State
Zip code
Primary phone
Secondary phone
Email
page 2
Full Name:
Medical Record #:
Choosing My Health Care Agent(s) (Decision Maker)
This section names someone I trust to make health care decisions for me if I am unable to make them
for myself.
Part 1
Choosing your
Health Care
Agent also
means sharing
your values &
beliefs with them
and telling them
what medical care
you would want if
you are unable to
make decisions
for yourself.
If my health care provider has determined that I am not able to make my
own health care decisions, this form names the person(s) I choose to make
health care decisions for me.
My health care agent (decision maker) will speak on my behalf to make health care
decisions for me based on the preferences I have shared with them or what they
believe to be in my best interest, considering what they know about my personal
values and beliefs.
Note: Talk to your agent about what is most important to you and make sure they
feel able to perform this role. Be sure to let those closest to you know who you
have chosen to be your agent.
Who should I choose
to be my health
care agent?
When choosing your health care agent, consider selecting a person
who is important to you and has the ability to make hard decisions in
a dicult time. Legally, your agent cannot be your doctor or another health
care professional who cares for you as part of your treatment team.
You cannot anticipate every health care situation; your agent will have to make
decisions in real-time based on information shared by the medical team.
Having discussions with your agent about the kind of care you want and do
not want will give you both a shared understanding and peace of mind.
Sometimes, a spouse or family member may be the best choice, sometimes
they are not the best choice. You know best.
A good health care agent is someone who:
• Is willing to be your health care agent and can be reasonably available
• Knows your values & beliefs well
• Is willing to honor and represent your preferences even if they are
dierent from their own
• Will not be afraid to ask questions and speak on your behalf,
even if it goes against convention or the wishes of loved ones
• Is able to make decisions under stress
• Will continue to check-in with you about your preferences over time
Note: Your health care agent may or may not be the same person you would
choose as an emergency contact.
This form does not authorize your agent to make nancial or other business
decisions for you.
page 3
Full Name:
Medical Record #:
Talk with your
Agent about
the kinds of
responsibilities
they might have
to take on in this
role. Use the
questions in
Part 2 to
guide your
conversation.
My health care agent may make ALL health care decisions for me if I am unable to
make them for myself. Unless I limit my agent’s authority, they can make the
following decisions for me:
• Say yes/no to medications, tests, treatments. Select or change health care
providers and decide where I will receive care
• Start, not start, or stop all forms of life sustaining interventions to keep
me alive
• Arrange for and make decisions about the care of my body after death
(including autopsy, organ donation, and what happens to my remains)
Choosing a Primary
health care agent.
I choose the following person to be my Primary (main) health care agent to make
health care decisions for me if I am unable to make them for myself.
My Primary (main) health care agent:
page 4
Full name
Relationship
Mailing address
City State
Zip code
Primary phone
Secondary phone
Email
My agent’s authority becomes eective when my physician determines
that I am unable to make my own health care decisions.
Please mark an “X” to select one of the following:
❑ I understand and accept that my agent will become active when
I can no longer make my own decisions, OR
❑ I prefer that my agent make decisions on my behalf immediately,
even though I am currently able to make my own decisions
Note: If your agent is a spouse or domestic partner, the agent designation is
revoked in the event of a dissolution, annulment, or termination of the marriage or
domestic partnership.
Full Name:
Medical Record #:
First & Second
Alternate health
care agent.
This section is
recommended
but optional.
If no one comes
to mind, move
forward.
page 5
If my Primary health care agent is not willing, able, or reasonably available to make
health care decisions for me, I choose the following to be my First and Second
Alternate agents.
First Alternate health care agent:
Full name
Relationship
Mailing address
City State
Zip code
Primary phone
Secondary phone
Email
Second Alternate health care agent:
Full name
Relationship
Mailing address
City State
Zip code
Primary phone
Secondary phone
Email
Full Name:
Medical Record #:
Health
care agent
limitations.
If nothing comes
to mind for
either of these
statements, move
forward.
page 6
If I wish to limit my health care agent’s authority, I will write below what health care
decisions I DO NOT want my agent to make.
I will also write below the names of any individuals, if any, who I DO NOT want to
make health care decisions for me.
Full Name:
Medical Record #:
My Values & Beliefs
This section lets me reect on what quality of life and living well mean to me. It serves as a foundation for
my responses to the rest of this document.
Part 2
Completing My
Values & Beliefs
section allows
you to write down
what is most
important in your
life. Take your
time with these
questions as they
will help you think
through Part 3
of this document.
page 7
It is important to understand and reect on what matters most so I can
make decisions in advance about my health care that match who I am.
It is also important for my health care agent (decision maker) to
understand my values and what matters most to me.
I will share some things about myself, such as what is most important in my life,
what living well means to me, and what abilities I value. I will also share how my
belief system may inuence my health care.
Check all that apply and use the space below to describe more.
1. For me to live well, the following matter most to me:
❑ Spending time and connecting with loved ones
❑ Making my own decisions
❑ Communicating meaningfully
❑ Being physically active
❑ Recognizing friends and family
❑ Being socially active
❑ Living independently
❑ Feeding myself without assistance
❑ Taking care of my personal hygiene (bathing, dressing myself)
❑ Living in my home
❑ Working and/or volunteering
❑ Participating in hobbies or interests
❑ Honoring my spiritual beliefs and/or religion
❑ Other (say more below)
It also matters to me that...
page 8
Full Name:
Medical Record #:
Think about what
you value most.
What does quality
of life mean to
you? These
might feel like
big questions,
but you already
know more than
you think.
2. This is WHY the choices I made in Question 1 matter to me. I will also
share additional thoughts about what brings meaning to my life.
Why are these important to you?
Only answer if this
is relevant to you.
3. How does my culture, spirituality, religion, and/or belief system inuence
my health care decisions? How important is this to me?
It is important to me that...
Full Name:
Medical Record #:
Choosing My Health Care Preferences
This section along with Part 2: My Values & Beliefs describes my preferences to guide my doctors
and health care agent to make medical decisions for me if I am unable to make my own health care
decisions AND life sustaining interventions are needed to keep me alive.
Part 3
Choosing your
Health Care
Preferences
might feel
uncomfortable,
but doing so while
you are healthy
gives you a voice
for a time when
you might not
have one.
This document represents my health care preferences:
If I am unable to make my own health care decisions and
life sustaining
interventions are needed to keep me alive, I ask that my health care agent
represent my health care preferences as described below.
I know that decisions will be made in partnership with my doctors and care
team and they will consider my values & beliefs, my health care preferences,
and my medical condition at the time decisions need to be made.
Note: By documenting your health care preferences in this directive, your health
care agent and doctors can make decisions based on what you have written rather
than guessing, assuming, or trying to remember. Discuss your preferences and your
values and beliefs with your agent and doctors.
What are life
sustaining
interventions?
Life sustaining interventions include any medical procedures, devices,
or medications that may be used to keep me alive.
These interventions may or may not work, and they do not treat the underlying
condition or cause of illness.
Life sustaining interventions include the following:
• Cardiopulmonary resuscitation (CPR): an attempt to restart the
heart with chest compressions if your heart and breathing were to stop.
• Ventilator: a machine that breathes for you when your lungs are not
working. A tube is inserted either through your mouth or an incision in
your neck into your airway. The tube connects to the machine.
• Tube feeding: also called articial nutrition, is a medical treatment that
provides liquid food (nutrition) to the body. This is done when a person
cannot eat enough by mouth or they have problems swallowing.
• Dialysis: a machine that removes waste from your blood if your
kidneys are not working.
• Blood transfusions or use of blood products for treatments:
the process of transferring blood or blood products into your body
through a narrow tube placed within a vein in your arm.
page 9
page 10
Full Name:
Medical Record #:
❑
❑
❑
❑
❑
❑
Share your values
and health care
preferences
with your agent.
Talk about why
your choices are
important to you.
Make sure they
will honor your
wishes even if
they might be
dierent from
their own.
Now that you have learned about life sustaining interventions, consider the
following (select as many abilities below as you would like).
A.
I would decline or stop life sustaining interventions if I was not able to:
Make my own decisions
Communicate meaningfully
Recognize friends and family
Feed myself without assistance or tube feeding
T
ake care of my personal hygiene (bathing, dressing myself)
Engage with the community
Based on your answers above, consider the following as you choose your health
care preferences below:
My health care agent is being asked to make medical decisions for me
because a serious medical event, illness, or injury has left me unable to
make my own decisions and life sustaining interventions are needed to
keep me alive. Life sustaining interventions include: CPR, ventilator, tube feeding,
dialysis, blood transfusions or blood products, etc.
In the situation
described, you
may not have
the ability to
recognize yourself
or loved ones.
The doctors have
told your agent
and/or family
that you are not
expected to
recover these
abilities.
B.
I have advanced dementia or severe brain damage that is not expected
to get better. I am not able to function in a way that is acceptable to me.
Based on my values and beliefs:
I do not want any life-sustaining interventions. I would either stop
or not start life sustaining interventions.
I would want life-sustaining interventions to start or continue,
as long as medically appropriate.
I want a limited trial of life-sustaining interventions, as long as
medically appropriate. Typically, a trial is less than two weeks.
My preferences for a trial period are...because...
page 11
Full Name:
Medical Record #:
Examples
of a serious,
progressing
illness may
include heart,
kidney, and lung
disease.
C. I have a serious, progressing illness that is nearing its nal stage.
I am not able to function in a way that is acceptable to me.
Based on my values and beliefs:
I do not want any life-sustaining interventions. I would either stop
or not start life sustaining interventions.
I would want life-sustaining interventions to start or continue,
as long as medically appropriate.
I want a limited trial of life-sustaining interventions, as long as
medically appropriate. Typically, a trial is less than two weeks.
My preferences for a trial period are...because...
Only answer if this
is relevant to you.
If I want to add any additional health care preferences, or if I wish to limit
any life sustaining interventions because of my cultural, religious,
or personal beliefs, I will write these limitation(s) in the space below.
I want...because...
page 12
Full Name:
Medical Record #:
[Optional] Decision
to decline specied
medical treatment.
Initial below if you want to decline blood transfusions or blood products for
treatment (select the option that is true for you).
I DECLINE blood transfusions or blood products and will ll out
the Kaiser Permanente Blood Declaration form.
I DECLINE blood transfusions or blood products and I have
completed a Kaiser Permanente Blood Declaration form.
Do I need
another form?
If you currently have a serious, progressing illness that is nearing its nal
stage, please discuss completing a POLST (Physician Orders for Life-Sustaining
Treatment) document with your doctor or health care team.
Full Name:
Medical Record #:
After-Death Preferences
This section allows you to record your preferences for how you want your body to be treated after death
and what your funeral, memorial or burial wishes may be. You can also document your preferences for
organ donation.
Part 4
Recording your
After-Death
Preferences
might feel dicult,
but it will help
your loved ones
follow through
on your wishes
during an
emotional time.
page 13
Documenting your preferences for what happens to you at death and after,
will help the people closest to you honor what is most important to you.
Take some time to reect on these statements and if it helps, you can refer back to
Part 2: My Values & Beliefs.
Remember: If you are struggling or don’t have all the answers, document what
you know and move forward.
1. If I am at the end of my life, I want my loved ones to know that I would
like the following around me (for example, rituals, spiritual support, people,
music, food, pets, etc.):
My preferences are...
Please also
include any prior
arrangements
(such as mortuary,
cemetery,
donation of your
body to science)
you may have
made.
2. After death, my preferences for how I want my body to be treated
(funeral, memorial, burial, or any other religious or spiritual traditions) are
listed below.
My preferences are...
page 14
Full Name:
Medical Record #:
Preferences for
organs, tissues,
and/or body parts
donation.
Choose one option for organ donation.
3. Upon my death, I want to donate my organs, tissues, and/or body parts.
❑ Yes
❑
❑
❑
❑
❑
❑
By checking the box above, and regardless of my choice in Part 3:
Choosing My Health Care Preferences for End of Life, I authorize my
health care agent to consent to any temporary medical procedure necessary
solely to evaluate and/or maintain my organs, tissues, and/or body parts for
purposes of donation.
Choose as many options as applies:
I want to donate my organs, tissues, and/or body parts for the following
purposes:
Transplant
Therapy
Resear
ch
Education
I want to restrict my donation of organs, tissues, and/or body parts as
indicated below:
I would like to restrict...
No
I’m not sure
If I leave this part blank, it is not a refusal to donate my organs, tissues,
and/or body parts. My state-authorized donor registration should be followed, or,
if none, my legally recognized decision maker listed in Part 1 may make a donation
upon my death. If no health care agent is named, I acknowledge that Califor
nia law
permits an authorized individual to make such a decision on my behalf.
Full Name:
Medical Record #:
Making This Document Legally Valid
This section makes your Advance Health Care Directive legally valid in the State of California. For it to be
legally valid, (1) you must sign AND (2) it must be signed by two witnesses OR acknowledged
before a Notary Public.
Part 5
Following legal
requirements
ensures that all
the work and
thinking you put
into this AHCD
will be valid.
Remember, if you
want to change
something later,
just complete
another AHCD.
Sign at the bottom of this page AND choose ONE of the following to make
this document legally valid in the State of California:
TWO WITNESSES
• 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 health care
agents (decision
makers) can NOT sign as
witnesses.
• Your
health provider, or an
employee of the health
care provider CANNOT
sign as a witness
• When you are with
your witnesses, sign or
acknowledge your signature.
• Witnesses will sign on
page 16.
OR
NOTARY PUBLIC
• Do NOT sign this document
unless you are with a Notary
Public.
• Notary Public will sign on
page 17.
page 15
Continue to the next page for witnessing and notary requirements.
Your signature here.
Keep going! For
this document to
be legally valid
in the State of
California, you
also have to get
this document
witnessed or
notarized.
My 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.
Full Name:
Medical Record #:
Choosing
TWO WITNESSES.
I choose TWO WITNESSES to make this document legally valid in California.
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 Health Care Directive in my presence, (3) That
the individual appears to be of sound mind and under no duress, fraud, or undue
inuence, (4) That I am not a person appointed as an agent by this Advance
Health Care 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.
Witness Number
One signature.
page 16
Remember, your
health care
agent cannot
be a witness.
Witness number one:
Name
Address
Signature Date
Witness Number
Two signature.
Witness number two:
Name
Address
Signature Date
Legally, one of
your witnesses
cannot be
related to you.
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 Date
Full Name:
Medical Record #:
Only sign if this
is r
elevant to you.
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
Choosing a
NOTARY PUBLIC.
I choose a NOTARY PUBLIC instead of two witnesses.
ACKNOWLEDGMENT
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.
State of California,
County of
On before me,
(insert name and title of the ocer)
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 ocial seal.
Signature (Seal)
page 17
Congratulations!
You’re almost
there. Here are a
few more things
to take care of
to nish up the
process.
Next Steps
Now that you have completed your Advance Health Care Directive (AHCD), use this
checklist to ensure that you follow up on these last few steps.
❑ Give copies of your AHCD
• T
o your health care agent (decision maker), and alternate agent(s)
• Bring to your next scheduled appointment OR
Send in a copy by mail to: Kaiser Permanente Central Scanning,
1011
S. East Street, Anaheim, CA 92805 OR
Email:
SCALCentralized-Scanning-Center@kp.org
• Keep
the original
❑ Discuss your AHCD
• T
alk to your health care agent (decision maker) about your values,
beliefs, and your health care preferences. Use your AHCD to guide the
conversation and make sure they feel able to perform this role.
• Be sure to let your loved ones, family, and/or close friends know
who you have chosen to be your health care agent and what your health
care preferences are and why.
❑ T
ake your AHCD with you
• If you go to a hospital or nursing home, take a copy of your AHCD and
ask that it be placed in your medical record.
❑ Review your AHCD regularly
Review your AHCD whenever any of the following occur:
Decade – when you start a new decade of your life
Death – whenever you experience the death of a loved one
Divorce/Marriage – when you experience a divorce, marriage, or other
major family change
Diagnosis – when you are diagnosed with a serious health condition
Decline – when you experience a signicant decline or deterioration of an
existing health condition, especially if you are unable to live on your own.
Remember: You can cancel or change ANY of your preferences in your
AHCD at any time. As things change in your life or with your health, you can
change who your health care agent (decision maker) is and what your medical
preferences are. You must do so in writing and sign the new document, or
you can inform your health care provider in-person.
page 18
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.
Developed by Spark, a KPIT Innovation team in partnership with the
regional Life Care Planning team. Special thanks to Bioethics, SCPMG
Legal, and other key contributors for their guidance.
© Southern California Permanente Medical Group.
All rights reserved.
SCAL-LCP 032E (07/21)
kp.org/lifecareplan
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