Advance Health Care Directive
This form lets you give instructions about your future health care. It also lets you name someone to make decisions for you if you can't make your own decisions. It's best if you fill out the whole form, but, as long as it is signed, dated and witnessed or notarized properly, you may choose only to appoint an agent or provide health care instructions.
1. Appointment of health care agent
If you choose not to name an agent, initial the box above, print your name on the line in the space provided, draw a line through the rest of this page, then continue to to Section 3
Your agent may not be:
A. Your primary treating health care provider.
B. An operator of a community care or residential care facility where you receive care.
C. An employee of the health care institution or community or residential care facility where you receive care, unless your agent is related to you or is one of your co-workers.
If you choose to name an agent, you should discuss your wishes with that person and give that person a copy of this form. You should make sure that this person understands and is willing to accept this responsibility.
Selection of agent
I hereby appoint as my agent to make health care decisions for me:
Name___________________________
Address_________________________
City____________________________
State______________
Home phone______________________
Work phone______________________
I understand that appointment will continue unless I revoke it as explained in Section 5
Alternative agents
If I revoke my agent's authority or if my agent is not reasonably available, able or willing to make health care decisions for me, I appoint the following person(s) to do so, listed in the order they should be asked:
First alternative
Name___________________________
Address_________________________
State___________________________
Home phone_____________________
Work phone_____________________
Second alternative
Name___________________________
Address_________________________
State___________________________
Home phone_____________________
Work phone_____________________
2. Authority of agent
Your agent must make health care decisions that are consistent with the instructions in this document and your known desires. It is important that you discuss your health care desires with the person(s) you appoint as your health care agent, and with your doctor(s). If your wishes are not known, your agent must make health care decisions that your agent believes to be your best interest, considering your personal values to the extent they are known.
If my primary physician finds that I cannot make my own health care decisions, I grant my agent full power and authority to make those decisions for me, subject to any health care instructions set forth below. My agent will have the right to:
A. Consent , refuse consent, or withdraw consent to any medical care or services, such as tests, drugs, or surgery, and hydration (tube feeding) and all other forms of health care, including cardiopulmonary resuscitation (CPR)
B. Choose or reject my physician, other health care professionals or health care facilities.
C. Receive and consent to the release of medical information.
D. Donate organs or tissues, authorize and autopsy and dispose of my body, unless I have said something different in a contract with a funeral home, in my will, or by some other written method.
I understand that, by law, my agent may not consent to committing me to or placing me in a mental health treatment facility, or to convulsive treatment, psychosurgery, sterilization or abortion.
Optional: I want my agent's authority to make health care decisions for me to start now, even though I am still able to make them for myself. I understand and authorize this statement as proved by my signature.
______________________________
signature
3. Health Care Instructions
You may, but are not required to, state your desires about the goals and types of medical care you do or do not want, including your desires concerning life support if you are seriously ill. If your wishes are not known, your agent must make health care decisions for you that your agent believes to be in your best interest, considering your personal values. If you do not wish to provide specific written health care instructions, draw a line through this section.
The following are statements about the use of life-support treatments. Life-support or life-sustaining treatments are any medical procedures, devices or medications used to keep you alive. Life-support treatments may include: medical devices put in you to help you breath; food and fluid supplied artificially by medical device (tube feeding); cardiopulmonary resuscitation (CPR); major surgery; blood transfusions; kidney dialysis; and antibiotics.
Sign either of the following general statements about life-support treatments if one accurately reflects your desires. If you wish to modify or add to either statement or to write your own statement instead, you may do so in the space provided or on a separate sheet(s) of paper which you must date and sign and attach to this form.
Optional: The statement I have signed below is to apply if I am suffering from a terminal condition from which death is expected in a matter of months, or if I am suffering from a irreversible condition that renders me unable to make decisions for myself, and life-support treatments are needed to keep me alive.
A. I request that all treatments other than those needed to keep me comfortable be discontinued or withheld and my physician(s) allow me to die as gently as possible. I understand and authorize this statement as proved by my signature _______________________________.
B. I request that attempts be made to keep me alive in this terminal or irreversible condition by using all available, effective life-support treatments. I understand and authorize this statement as proved by my signature__________________________________________.
Optional: Other or additional statements of medical treatment desires and limitation:
________________________________________________________
________________________________________________________
________________________________________________________
Optional: I have added _____ page(s) of specific health care instructions to this directive, each of which is signed and dated on the same day I signed this directive.
4. ORGAN AND TISSUE DONATION
If you wish to be an organ donor, initial the box below.
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If you do not wish to be an organ donor, draw a line through this Section 4.
5. PRIOR DIRECTIVES REVOKED
I revoke any prior Power of Attorney for Health Care or Natural Death Act Declaration..
You may revoke any part of or this entire Advance health Care Directive at any time. To revoke the appointment of an agent, you must inform your treating health care provider personally or in writing. Completing a new California Medical Association Advance Health Care Directive will revoke all previous directives. If you revoke a prior directive , Notify every person and hospital, clinic, or care facility that has a copy of your prior directive and give them a copy of your new directive.
DATE AND SIGNATURE OF PRINCIPAL
I sign my name to and acknowledge this Advance Health Care Directive at:
_____________________________
(signature of principal)
_____________________________
(street address)
_____________________________
(city and state)
_____________________________
(date)
7. STATEMENT OF WITNESSES
This Advance Health Care Directive will not be valid unless it is either (1)signed by two qualified adult witnesses who are present when you sign or acknowledge your signature or (2) acknowledged befpre a notary public in California. If you use witnesses rather than a notary public, the law prohibits using the following as witnesses: (1) the persons you have appointed as your agent or alternate agents(s); (2) your health care provider or an employee of your health care provider; or (3) an operator or employee of an operator of a community care facility or residential care facility for the elderly. Additionally, at least one of the witnesses cannot be related to you by blood, marriage or adoption, or be named in your will, or by operation of law be entitled to any portion of your estate upon your death.
Special Rules for Skilled Nursing Facility Residents
If you are a patient in a skilled nursing facility, you must have a patient advocate or ombudsman sign as a witness and sign the Statement of Patient Advocate or Ombudsman. (See following page.) You must also have a second qualified witness sign below or have this document acknowledged before a notary public.
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 know to me, or that the the individual's identity was proven to me by convincing evidence (*see next page), (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 influence, (4) that I am not a person appointed as agent by this Advance Health Care Directive, and (5). I am not the individual's health care provider nor an employee of that health care provider, nor an operator or employee of an operator of a community care facility or residential care facility for the elderly.
First Witness______________________ _________________ __________________________
(name printed) (date) (signature)
Residence Address:________________________________________________________________
Second Witness___________________ _________________ __________________________
(name printed) (date) (signature)
Residence Address__________________________________________________________________
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.
____________________________________ _________________
(signed) (date)
FOR SKILLED NURSING FACILITIES: STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN
if you are a patient in a skilled nursing facility, a patient advocate or ombudsman must sign the Statement of Witnesses above, and must also sign the following declaration.
I further declare under penalty of perjury under these laws of California that I am a patient advocate or ombudsman as designated by the State Department of Aging and am serving as a witness as required by Probate Code 4675.
Name/Title Printed____________________________ Signature___________________________
Date________________ Address__________________________________________________
8. CERTIFICATE OF ACKNOWLEGEMENT OF NOTARY PUBLIC
Acknowledgement before a notary public is not required if two qualified witnesses have signed on page 3. If you are a patient in a skilled nursing facility , you must have a patient advocate or ombudsman sign the Statement of Witnesses on page 3 and the Statement of Patient Advocate on Ombudsman above, even if you also have this form notarized.
State of California
County of__________________________
On this_____________, before me, ___________________________________
(date) (Name and Title of Officer)
personally appeared _______________________________________________
(Name(s) of Signer(s))
personally known to me (or 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 behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and official seal.
_____________________________
(signature) Notary Seal
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