The California Advanced Health Care Directive form is a legal document that allows individuals to outline their preferences for medical treatment in the event they are unable to make decisions for themselves. This form empowers a designated agent to make health care decisions on the individual's behalf, ensuring their medical care aligns with their wishes. It is an essential tool for anyone seeking to have control over their future health care.
When it comes to planning for future healthcare decisions, having clear and precise directives in place is crucial. This is where the California Advanced Health Care Directive form plays a vital role. It's a legal document that allows individuals to outline their preferences for medical treatment and appoint someone they trust to make health care decisions on their behalf, should they become unable to do so. The form is designed to ensure that a person’s healthcare wishes are respected and followed, even when they're not in a position to communicate them directly. Covering a broad spectrum of medical decisions, from life-sustaining treatments to organ donation preferences, this document provides a comprehensive approach to planning for future healthcare needs. It's a key component of estate planning, but with the focus squarely on the individual’s health and personal values. Understanding this form's importance and ensuring it accurately reflects one’s wishes can offer peace of mind to both the individual and their loved ones, making difficult decisions a little easier during challenging times.
ADVANCE HEALTH CARE DIRECTIVE FORM
PAGE 1 of 7
Print Form
Reset Form
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.
PAGE 2 of 7
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)
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)
(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.
PAGE 3 of 7
(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:
:
(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:
(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:
PAGE 4 of 7
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
(4.1) I designate the following physician as my primary physician:
(name of physician)
(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:
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)
(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)
(city)(state)
(signature of witness)
(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.
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.
(Amended by Stats. 2018, Ch. 287, Sec. 1. (AB 3211) Effective January 1, 2019.)
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)
The California Advanced Health Care Directive form is a crucial document for anyone who wishes to have a say in their medical treatment in the event they are unable to communicate their wishes themselves. This form allows individuals to appoint an agent to make health care decisions on their behalf and to specify what medical treatments they do or do not want. It's a proactive step that ensures people's health care preferences are known and respected. Properly completing and signing this form is an important task that requires attention to detail. Follow these steps to fill out the California Advanced Health Care Directive form accurately.
Completing the California Advanced Health Care Directive form is a significant way to ensure that your health care preferences are understood and acted upon in difficult circumstances. It gives peace of mind not just to you, but also to your family, and your health care providers, making it an essential document for everyone.
What is a California Advanced Health Care Directive form?
The California Advanced Health Care Directive form is a legal document that lets you outline your preferences for medical treatment and care in case you're unable to speak for yourself. This might be due to sickness or injury. It allows you to appoint someone you trust to make health care decisions on your behalf. This form ensures your health care wishes are known and considered by family members and health care providers.
How do I choose someone to make health care decisions for me?
When choosing a health care agent, think about someone who understands your values and wishes about your health care. This should be a person you trust to make decisions in your best interest, who can handle stress during tough times, and is willing to communicate with health care providers and family members. It can be a family member, a friend, or anyone you feel comfortable with. Make sure to discuss your health care preferences with them before appointing them in your directive.
Can I change my Advanced Health Care Directive once it's been completed?
Yes, you can change or cancel your Advanced Health Care Directive at any time while you're still capable of making decisions. To do so, you can either complete a new directive form or make a written statement that meets the legal requirements. It's important to inform your health care agent, family, and health care providers of any changes you make to ensure your current wishes are known.
Do I need a lawyer to complete an Advanced Health Care Directive in California?
No, you don't need a lawyer to complete an Advanced Health Care Directive in California. The form is designed to be straightforward so that you can fill it out on your own. However, if you have specific legal questions or your health care wishes involve complex arrangements, consulting with a lawyer might be helpful. Remember to follow the instructions carefully and ensure your form is properly signed and witnessed or notarized, as required by California law.
When filling out the California Advanced Health Care Directive form, it's important to take your time and pay close attention to detail. This document plays a vital role in your healthcare, making decisions on your behalf if you're unable to do so yourself. Unfortunately, mistakes can happen, leading to unnecessary confusion or even disputes among family members. Let's explore some common errors that people often make:
Not Specifying Preferences Clearly: Many individuals fail to clearly outline their healthcare preferences, including conditions under which they would refuse certain treatments. This vagueness can leave loved ones and healthcare providers uncertain about your wishes.
Forgetting to Sign and Date the Form: It may seem basic, but it's surprisingly common. If the form is not signed and dated, it won't be legally valid, rendering your carefully considered directives ineffective.
Neglecting to Assign an Alternate Agent: While you may have a trusted primary agent, it's crucial to designate an alternate. Life's uncertain, and if your primary agent is unable to serve, an alternate can step in without delay.
Failing to Discuss Your Wishes with Your Agent: Simply choosing an agent isn't enough. For your agent to advocate effectively on your behalf, they must fully understand your healthcare preferences and the reasoning behind them.
Omitting a Signature from a Witness or Notary: Depending on the method of validation you choose, the absence of a witness or notary signature can invalidate the entire document, even if every other portion is completed meticulously.
Using Unclear Language or Medical Terms: Employing technical medical terms without clear definitions or explanations can lead to misinterpretation of your wishes, potentially leading to treatments you would have declined.
Not Updating the Form After Major Life Changes: Life events such as marriages, births, and diagnoses can significantly alter your healthcare preferences. A directive should be updated to reflect these changes but is often overlooked.
Failure to Distribute Copies to the Right People: Completing your directive is a crucial step, but it's equally important to ensure that your healthcare providers, agent, and any alternates have copies. If the right people don't have access to your directive, your wishes may not be honored.
Steering clear of these mistakes can greatly improve the effectiveness of your California Advanced Health Care Directive. It ensures that your healthcare wishes are known, understood, and able to be acted upon. Careful attention to completing and maintaining this document can provide peace of mind to you and your loved ones.
When preparing for the future, particularly in matters of health and personal welfare, the California Advanced Health Care Directive form often comes into play. This critical document allows individuals to outline their preferences for medical treatment and appoint a health care agent. However, to ensure one's wishes are fully respected and legal matters are comprehensively covered, several other forms and documents are frequently used alongside it. Each serves a specific purpose, complementing the directive to create a well-rounded legal and personal plan.
Utilizing these seven documents in conjunction with the California Advanced Health Care Directive provides a comprehensive approach to personal and estate planning. It ensures wishes are respected and affairs are in order, allowing for peace of mind. Each document plays a critical role in safeguarding one's health, financial, and personal decisions, painting a complete picture of one's preferences for the future.
Living Will: Similar to the California Advanced Health Care Directive, a living will document specifies a person's preferences for medical treatment if they become unable to communicate or make decisions. Both documents guide healthcare professionals and family on end-of-life care, but the living will specifically focuses on life-sustaining treatment preferences.
Medical Power of Attorney (POA): This legal document, much like the Advanced Health Care Directive, allows an individual to appoint someone else to make healthcare decisions on their behalf if they are incapacitated. The key similarity lies in empowering another person to act in one's best interest regarding medical issues.
Durable Power of Attorney: The Durable Power of Attorney shares similarities with the health care directive in that it enables one to designate another person to make decisions on their behalf. While the health care directive focuses on medical decisions, a durable power of attorney can pertain to financial or other personal affairs but embodies the same principle of delegated authority.
Do Not Resuscitate (DNR) Order: Similar to the Advanced Health Care Directive, a DNR order instructs healthcare providers not to perform life-saving measures like CPR in the event of a patient's heart or breathing stopping. Both documents are vital in planning for medical emergencies and end-of-life care preferences.
POLST Form (Physician Orders for Life-Sustaining Treatment): This form complements the California Advance Health Care Directive by providing specific instructions about certain types of life-sustaining treatments. While the Advance Directive sets out broader health care preferences and agent designation, POLST forms give detailed medical orders based on those preferences, particularly useful in emergency situations.
Last Will and Testament: Although primarily focused on the distribution of an individual's assets after their death, a Last Will and Testament shares the concept of planning for the future with an Advance Health Care Directive. Both documents ensure a person's wishes are known and respected, albeit in different domains (medical vs. estate).
Health Information Authorization: This document, under laws like HIPAA in the United States, allows individuals to specify who can receive their medical information. It aligns with the Advance Health Care Directive's aspect of sharing critical health care decisions and information with designated agents or family members.
Mental Health Advance Directive: Similar to the general Advance Health Care Directive, this document specifies one's preferences for psychiatric treatment and appoints an agent to make mental health care decisions on their behalf if they are incapacitated. It is specifically tailored to individuals with mental health considerations.
Organ and Tissue Donation Registration: Like the Advanced Health Care Directive, which may include instructions for organ donation, registering as an organ donor specifies one’s wishes regarding the donation of organs and tissues after death. Both documents ensure a person's health care preferences, including posthumous gifts of life, are honored.
When it comes to planning for one's health care, the California Advanced Health Care Directive form is a crucial tool. It allows individuals to outline what medical actions should be taken for their health if they are no longer able to make decisions due to illness or incapacity. Below are key dos and don'ts to keep in mind when filling out this important document.
Dos
Don'ts
When it comes to making decisions about future healthcare, the California Advanced Health Care Directive (AHD) form is a crucial tool. However, there's a fair amount of misunderstanding surrounding it. Let’s clarify some common misconceptions:
When approaching the California Advanced Health Care Directive form, it's crucial to understand its purpose and details for optimal use. This document allows you to outline your wishes for medical treatment in scenarios where you cannot communicate them yourself. Here are key takeaways to ensure accurate and beneficial completion and utilization of the form:
Proper completion and management of the California Advanced Health Care Directive form ensure that your healthcare wishes are known and respected, providing peace of mind for you and your loved ones.
Dea Prescription Pads - A document used by doctors to authorize the dispensing of medications to patients.
Progressive Logo Transparent - The card includes a notice to always be kept in the vehicle, ready to be presented as proof of insurance during traffic inquiries or at accident scenes.
Navpers 1336 3 - Designed to streamline the application process for special requests, the form exemplifies the Navy's structured approach to personnel management.