2009 04-16 Advance Health Care Directive Form and Instructions

Advance Health Care Directive Form Instructions
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.
The Advance Health Care Directive form lets you do one or both of these things. It also lets you
write down your wishes about donation of organs and the selection of your primary physician.
If you use the form, you may complete or change any part of it or all of it. If you do not agree
with the language in this pre-made form, change the language. Only sign a form after you are
certain that it truly reflects your specific wishes.
INSTRUCTIONS
Part 1: Power of Attorney
service, or procedure to maintain, diagnose, or
otherwise affect a physical or mental condition.
Part 1 lets you:
• Choose or discharge health care providers (i.e.
choose a doctor for you) and institutions.
• name another person as agent to make health
care decisions for you if you are unable to make
your own decisions. You can also have your
agent make decisions for you right away, even if
you are still able to make your own decisions.
• 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.
• Agree or disagree to diagnostic tests, surgical
procedures, and medication plans.
• Agree or disagree with providing, withholding,
or withdrawal of artificial feeding and fluids and
all other forms of health care, including
cardiopulmonary resuscitation (CPR).
• After your death make anatomical gifts (donate
organs/tissues), authorize an autopsy, and make
decisions about what will be done with your
body.
• your supervising health care provider (the doctor
managing your care)
Part 2: Instructions for Health Care
• an employee of the health care institution where
you are receiving care, unless your agent is
related to you or is a coworker.
You can give specific instructions about any aspect
of your health care, whether or not you appoint an
agent.
Your agent may make all health care decisions for
you, unless you limit the authority of your agent.
If you want to limit the authority of your agent the
form includes a place where you can do this.
There are choices provided on the form to help you
write down your wishes regarding providing, withholding or withdrawal of treatment to keep you
alive.
If you choose not to limit the authority of your
agent, your agent will have the right to:
You can also add to the choices you have made or
write out any additional wishes.
• Consent or refuse consent to any care, treatment,
You do not need to fill out part 2 of this form if you
want to allow your agent to make any decisions
about your health care that he/she believes best for
you without adding your specific instructions.
Part 3: Donation of Organs
witnesses (see the statements of the witnesses
included in the form) or acknowledged before a
notary public. A notary is not required if the
form is signed by two witnesses. The witnesses
must sign the form on the same date it is signed
by the person making the Advance Directive.
You can write down your wishes about donating
your bodily organs and tissues following your
death.
See part 6 of the form if you are a patient in a
skilled nursing facility.
Part 4: Primary Physician
Part 6: Special Witness Requirement
You can select a physician to have primary or main
responsibility for your health care.
A Patient Advocate or Ombudsman must witness
the form if you are a patient in a skilled nursing
facility (a health care facility that provides skilled
nursing care and supportive care to patients).
See Part 6 of the form.
Part 5: Signature and Witnesses
After completing the form, sign and date it in the
section provided.
The form must be signed by two qualified
You have the right to change or revoke your Advance Health Care
Directive at any time
If you have questions about completing the Advance Directive in the hospital,
please ask to speak to a Chaplain or Social Worker.
We ask that you
complete this form in English
so your caregivers can understand your directions.
Advance Health Care Directive
Name ________________________________________________
Date________________
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 also lets you write down your wishes regarding donation
of organs and the designation of your primary physician. If you use the form, you may complete or change any
part of it or all of it. If you do not agree with the language in this pre-made form, change the language. Only
sign a form after you are certain that it truly reflects your specific wishes.
.
You have the right to change or revoke this advance health care directive 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:______________________________________
Relationship_________________________________
Address:__________________________________________________________________________________
___________________________________________________________
Telephone numbers: (Indicate home, work, cell)
__________________________________________________________________________
ALTERNATE AGENT (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 alternate agent:______________________________________________
Relationship_________________________________
Address:__________________________________________________________________________________
_________________________________________________________________________________________
Telephone numbers: (Indicate home, work, cell)
_________________________________________________________________________________________
SECOND ALTERNATE AGENT (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: __________________________________________________________________________________
__________________________________________________________________________________________
Telephone numbers: (Indicate home, work, cell) ________________________________________________
(1.2) AGENT’S AUTHORITY: My agent is authorized to 1) 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, 2) to choose a particular physician or health care facility, and 3) to receive or
consent to the release of medical information and records, 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 initial
the following line.
If I initial this line, my agent’s authority to make health care decisions for me takes effect immediately. ____
(1.4) 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 my best interest. In determining my
best interest, my agent shall consider my personal values to the extent known to my agent.
(1.5) AGENT’S POST DEATH 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. ______ (initial here)
Part 2 — Instructions for Health Care
If you fill out this part of the form, you may strike out any wording you do not want.
(2.1) END-OF-LIFE DECISIONS: I direct my health care providers and others involved in my care to
provide, withhold, or withdraw treatment in accordance with the choice I have marked below:
ο a) Choice Not To Prolong
I do not want my life to be prolonged if the likely risks and burdens of treatment would outweigh the
expected benefits, or if I become unconscious and, to a realistic degree of medical certainty, I will not
regain consciousness, or if I have an incurable and irreversible condition that will result in my death in
a relatively short time.
Or
ο b) Choice To Prolong
I want my life to be prolonged as long as possible within the limits of generally accepted medical
treatment standards.
(2.2) OTHER WISHES: If you have different or more specific instructions other than those marked above,
such as: what you consider a reasonable quality of life, treatments you would consider burdensome or
unacceptable, write them here. Add additional sheets if needed.)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________________________________________________________________
Part 3 — Donation of Organs at Death (Optional)
(3.1) Upon my death (mark applicable box):
ο I give any needed organs, tissues, or parts
ο I give the following organs, tissues or parts only:_____________________________________________
ο I do not wish to donate organs, tissues or parts.
My gift is for the following purposes (strike out any of the following you do not want):
Transplant
Therapy
Research
Education
Part 4 — Primary Physician (Optional)
(4.1) I designate the following physician as my primary physician:
Name of Physician:________________________________________________________________________
Address: ________________________________________________________________________________
________________________________________________________________________________________
Telephone: ______________________________________________________________________________
Part 5 — Signature
(5.1) EFFECT OF ACOPY: A copy of this form has the same effect as the original.
(5.2) SIGNATURE: Sign name: _______________________________________ Date: ______________
(5.3) 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 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
Print Name: ______________________________________________________________________________
Address: _________________________________________________________________________________
_________________________________________________________________________________________
Signature of Witness: ________________________________________ Date: ________________________
SECOND WITNESS
Print Name: ______________________________________________________________________________
Address:
__________________________________________________________________________________________
__________________________________________________________________________________________
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 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 on his or her death under a will now existing or by
operation of law.
Signature of Witness: ______________________________________________________________________
Signature of Witness: ______________________________________________________________________
Part 6 — Special Witness Requirement if in a Skilled Nursing Facility
(6.1) The patient advocate or ombudsman must sign the following statement:
STATEMENT OF PATIENT ADVOCATE OF 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:
Print Name:___________________________________ Signature: ________________________________
Address: _________________________________________________________ Date: _________________
Certificate of Acknowledgement of Notary Public (Not required if signed by two witnesses)
State of California, County of ___________________________________________ On this ________ day of
___________________________ , _____________ , before me, the undersigned, a Notary Public in and for
said State, personally appeared _____________________________________ , personally known to me or
proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the
within instrument, and acknowledged to me that he/she executed it.
Seal
WITNESS my hand an official seal.
Signature______________________________________