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The California Advanced Health Care Directive form plays a crucial role in ensuring that individuals can express their medical preferences in advance of any health crisis. This legal document allows a person to appoint a health care agent, someone who will make medical decisions on their behalf if they become unable to communicate. Additionally, the form provides space for individuals to outline specific wishes regarding medical treatment, including life-sustaining measures and end-of-life care. By addressing both the appointment of a decision-maker and the articulation of personal health care preferences, the directive empowers individuals to maintain control over their medical care. It also helps alleviate the burden on family members during difficult times by clarifying the individual’s wishes. Overall, the California Advanced Health Care Directive serves as a vital tool in promoting patient autonomy and ensuring that health care decisions align with personal values and beliefs.

California Advanced Health Care Directive Preview

ADVANCE HEALTH CARE DIRECTIVE FORM

 

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Probate Code - PROB

DIVISION 4.7. HEALTH CARE DECISIONS [4600 - 4806] ( Division 4.7 added by Stats. 1999, Ch. 658, Sec. 39. ) PART 2. UNIFORM HEALTH CARE DECISIONS ACT [4670 - 4743] ( Part 2 added by Stats. 1999, Ch. 658, Sec. 39. )

CHAPTER 2. Advance Health Care Directive Forms [4700 - 4701] ( Chapter 2 added by Stats. 1999, Ch. 658, Sec. 39. )

4701. The statutory advance health care directive form is as follows:

ADVANCE HEALTH CARE DIRECTIVE

(California Probate Code Section 4701)

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 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, or your supervising health care provider or employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker.)

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.

(c)Approve or disapprove diagnostic tests, surgical procedures, and 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.

(e)Donate your organs, tissues, and parts, authorize an autopsy, and direct disposition of remains.

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 also 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 at the end. 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 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.

ADVANCE HEALTH CARE DIRECTIVE FORM

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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)

(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)

 

 

(1.2) 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.)

(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 mark the following box.

If I mark this box , my agent's authority to make health care decisions for me takes effect immediately.

ADVANCE HEALTH CARE DIRECTIVE FORM

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(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 in 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 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 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 wiling, able, or reasonably available to act as conservator, I nominate the alternate agents whom I have named, in the order designated.

PART 2

INSTRUCTIONS FOR HEALTH CARE

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

(2.1) 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:

(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, OR

(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.

(2.2) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:

(Add additional sheets if needed.)

(2.3) 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.)

 

ADVANCE HEALTH CARE DIRECTIVE FORM

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PART 3

 

 

DONATION OF ORGANS, TISSUES, AND PARTS AT DEATH

 

 

(OPTIONAL)

 

(3.1)

Upon my death, I give my organs, tissues, and parts (mark box to indicate yes).

 

By checking the box above, and notwithstanding my choice in Part 2 of this form, 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.

My donation is for the following purposes (strike any of the following you do not want):

(a)Transplant

(b)Therapy

(c)Research

(d)Education

If you want to restrict your donation of an organ, tissue, or part in some way, please state your restriction on the following lines:

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. (To state any limitation, preference, or instruction regarding donation, please use the lines above or in Section 1.5 of this form).

PART 4

PRIMARY PHYSICIAN

(OPTIONAL)

(4.1) 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)

ADVANCE HEALTH CARE DIRECTIVE FORM

PART 5

PAGE 5 of 7

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

(5.2) SIGNATURE: Sign and date the form here:

(date)

(sign your name)

(address)

(print your name)

(city) (state)

(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

Second witness

(print name)

(address)

(city)(state)

(print name)

(address)

(city)(state)

(signature of witness)

(signature of witness)

(date)

(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 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 of witness)

(signature of witness)

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 6 of 7

 

PART 6

SPECIAL WITNESS REQUIREMENT

(6.1) The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. 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 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.

(date)

(sign your name)

(address)

(print your name)

(city) (state)

 

(Amended by Stats. 2018, Ch. 287, Sec. 1. (AB 3211) Effective January 1, 2019.)

ADVANCE HEALTH CARE DIRECTIVE FORM

PAGE 7 of 7

ACKNOWLEDGMENT

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.

State of California,

County of

On

before me,

(insert name and title of 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)

 

 

 

Common mistakes

  1. Not clearly identifying the health care agent. It's essential to choose someone who understands your wishes and can make decisions on your behalf.

  2. Failing to discuss your wishes with your chosen agent. A conversation about your values and preferences is crucial to ensure they can advocate for you effectively.

  3. Using vague language when describing medical preferences. Specific instructions help your agent understand your desires in various situations.

  4. Neglecting to update the directive after significant life changes. Major events, like marriage or divorce, may require you to revise your choices.

  5. Not signing and dating the form correctly. A missing signature can render the document invalid.

  6. Overlooking the need for witnesses or notarization. California law requires specific formalities to ensure the directive is legally binding.

  7. Forgetting to provide copies to relevant parties. Share the directive with your health care agent, family, and medical providers to ensure everyone is informed.

  8. Ignoring the importance of periodic reviews. Regularly revisit your directive to ensure it still reflects your current wishes and circumstances.

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Dos and Don'ts

When filling out the California Advanced Health Care Directive form, it’s important to approach the task with care and consideration. This document allows individuals to express their wishes regarding medical treatment and appoint someone to make decisions on their behalf if they are unable to do so. Here are ten important dos and don’ts to keep in mind:

  • Do read the entire form carefully before you begin.
  • Do discuss your wishes with family members and your chosen health care agent.
  • Do be specific about your preferences for medical treatment.
  • Do ensure that your chosen health care agent understands your values and wishes.
  • Do sign and date the form in the presence of a witness or notary, as required.
  • Don't rush through the form without thinking about your choices.
  • Don't use vague language that could lead to misunderstandings.
  • Don't forget to update the directive if your circumstances or wishes change.
  • Don't assume that your family will know your preferences without discussing them.
  • Don't leave the form unsigned or incomplete, as this may invalidate it.

By following these guidelines, you can ensure that your California Advanced Health Care Directive accurately reflects your wishes and provides clarity to your loved ones during difficult times.

Misconceptions

The California Advanced Health Care Directive (AHCD) is an important legal document that allows individuals to express their healthcare preferences in advance. However, several misconceptions surround this form. Here are five common misunderstandings:

  1. Misconception 1: The AHCD is only for elderly people.

    This is not true. Anyone over the age of 18 can complete an Advanced Health Care Directive. Health care decisions may need to be made at any age, so it’s wise for everyone to consider having one.

  2. Misconception 2: Completing the AHCD means I’m giving up control over my healthcare decisions.

    In fact, the AHCD allows you to maintain control by specifying your wishes. It ensures that your preferences are respected, even if you cannot communicate them at the time.

  3. Misconception 3: The AHCD is the same as a living will.

    While both documents relate to healthcare decisions, they are not identical. A living will typically focuses on end-of-life care, whereas the AHCD covers a broader range of healthcare decisions.

  4. Misconception 4: I can only appoint one person to make decisions for me.

    You can appoint multiple individuals as agents in your AHCD. This can provide flexibility and ensure that your wishes are honored, even if your primary agent is unavailable.

  5. Misconception 5: Once I fill out the AHCD, I cannot change it.

    This is incorrect. You can update or revoke your Advanced Health Care Directive at any time, as long as you are mentally competent. Regularly reviewing your directive is a good practice.

Understanding these misconceptions can help you make informed decisions about your healthcare preferences and ensure that your wishes are respected.

Detailed Guide for Using California Advanced Health Care Directive

Filling out the California Advanced Health Care Directive form is an important step in planning for your future health care needs. This document allows you to express your wishes regarding medical treatment and appoint someone to make decisions on your behalf if you are unable to do so. Follow these steps to complete the form accurately.

  1. Obtain the California Advanced Health Care Directive form. You can find it online or request a hard copy from a healthcare provider.
  2. Read the instructions carefully to understand each section of the form.
  3. In the first section, provide your full name and contact information. This ensures your identity is clear.
  4. Designate an agent. This person will make health care decisions for you if you cannot. Write their name, relationship to you, and contact information.
  5. Decide on any specific wishes regarding medical treatment. Be clear about what types of care you do or do not want.
  6. Consider adding a second agent in case your first choice is unavailable. Fill in their details if you choose to do so.
  7. Sign and date the form. Ensure that you are in a sound state of mind when doing this.
  8. Have the form witnessed by at least two individuals who are not related to you and who will not benefit from your estate.
  9. Make copies of the completed form for yourself, your agent, and your healthcare provider.