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When it comes to planning for future healthcare decisions, the California Advanced Health Care Directive form plays an essential role for residents of the state. This important document allows individuals to express their healthcare preferences in advance, ensuring that their wishes are honored even if they become unable to communicate them at a future time. By designating someone as a healthcare agent, individuals can delegate the authority to make medical decisions on their behalf. Additionally, the form provides a space for specifying personal wishes regarding treatments, ensuring that one’s values and beliefs guide the decision-making process. The directive covers a wide array of medical procedures, from life-sustaining treatments to palliative care, enabling individuals to align their healthcare choices with their personal philosophy. Understanding how to fill out this form and the significance of its provisions can empower individuals to take control of their health care, making this directive not just a legal tool, but a profound expression of personal autonomy.

Sample - California Advanced Health Care Directive Form

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

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(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

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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

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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)

 

 

 
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Form Information

Fact Name Description
Purpose The California Advanced Health Care Directive allows individuals to outline their healthcare preferences and appoint a healthcare agent to make decisions on their behalf if they are unable to do so.
Governing Law California Probate Code Sections 4650-4690 govern the creation and implementation of the Advanced Health Care Directive.
Eligibility Any adult aged 18 or older may complete and sign the directive to ensure their healthcare wishes are respected.
Revocation The directive can be revoked at any time by the individual, providing they are capable of making decisions.
Witness Requirements Two witnesses or a notary public must sign the directive to validate it, ensuring the document meets legal requirements.

Detailed Guide for Filling Out California Advanced Health Care Directive

Completing the California Advanced Health Care Directive form is an important task that can help ensure your healthcare preferences are known. Follow these steps carefully to accurately fill out the form.

  1. Obtain a copy of the California Advanced Health Care Directive form. You can find it online or request a copy from a legal office.
  2. Read through the entire form to understand the sections and requirements before you start filling it out.
  3. Begin by writing your full name and date of birth at the top of the form.
  4. Designate a healthcare agent in the first section. This person will make medical decisions for you if you are unable to do so.
  5. Provide an alternate agent if you wish, in case your primary choice is unavailable.
  6. Next, you will find sections to indicate your wishes regarding medical treatment. Clearly state your preferences, including any specific instructions.
  7. Review additional options regarding organ donation and other health care preferences, and check the appropriate boxes to express your wishes.
  8. Sign and date the form at the designated space. Ensure you do this in the presence of a witness or a notary public, as required.
  9. Make copies of the completed form. Keep one for yourself and provide copies to your healthcare agent and family members.

Obtain Answers on California Advanced Health Care Directive

  1. What is a California Advanced Health Care Directive?

    A California Advanced Health Care Directive is a legal document that allows individuals to outline their health care preferences in advance. It provides instructions for medical treatment and designates someone to make decisions on your behalf if you become unable to do so.

  2. Who can create an Advanced Health Care Directive?

    Any adult who is at least 18 years old and of sound mind can create an Advanced Health Care Directive. It is advisable for everyone to have one in place, as it ensures that your health care wishes are respected, regardless of age or health status.

  3. What decisions can I make in the directive?

    You can specify your preferences regarding life-sustaining treatments, resuscitation, pain management, organ donation, and more. The directive allows you to express your wishes about the types of medical care you want or do not want, which your appointed representative can use to guide decisions.

  4. What is a health care proxy?

    A health care proxy, also known as a health care agent, is the person you appoint to make medical decisions on your behalf. This person should be someone you trust, who understands your values and can advocate for your wishes when you cannot speak for yourself.

  5. How do I properly complete the Advanced Health Care Directive?

    You should fill out the form by providing personal details, including your name, address, and the name of your health care agent. It's crucial to clearly state your wishes regarding medical treatment. After completing the form, sign it in the presence of at least one witness or a notary public, as required by California law.

  6. Can I change my Advanced Health Care Directive?

    Yes, you can change or revoke your Advanced Health Care Directive at any time. To make changes, simply draft a new directive, clearly stating that it replaces the previous one, and follow the same signing and witnessing process. Inform your health care agent and any relevant medical providers of the changes.

  7. Where should I keep my Advanced Health Care Directive?

    Store your completed directive in a safe place but ensure that your health care agent, family members, and other relevant parties have copies. Additionally, consider providing a copy to your primary care physician and any hospital where you receive care.

  8. Does an Advanced Health Care Directive only apply to terminal illnesses?

    No, an Advanced Health Care Directive can apply to a variety of medical situations, not just terminal illnesses. It covers any case in which you are unable to communicate your wishes due to factors such as severe injury, illness, or unconsciousness.

  9. Is the Advanced Health Care Directive valid in other states?

    While a California Advanced Health Care Directive is generally recognized in other states, requirements may differ. If you travel or move, it's wise to confirm whether your directive meets the legal standards in that state or consult with local legal resources for guidance.

Common mistakes

Filling out the California Advanced Health Care Directive (AHCD) form is an important step in expressing one's health care preferences. However, individuals often make several common mistakes during this process that can lead to confusion or unintended consequences. One such mistake is failing to discuss their choices with family members or loved ones. Open conversations about health care preferences are essential to ensure that designated agents understand the individual's wishes.

Another frequent error is not completing the form in its entirety. Incomplete forms can create ambiguity regarding the individual's desires. It is crucial to address all sections of the directive, including specifying agents for health care decisions and detailing any particular preferences regarding medical treatment.

People sometimes overlook the need for signatures and witnesses. The California AHCD requires that the document be signed by the individual executing it and witnessed by at least two people or notarized. Failing to meet these requirements may result in the directive being considered invalid.

A lack of specificity in the document can also lead to issues. Some individuals may choose vague terms when expressing their health care preferences. Using precise language helps avoid misunderstandings. Clear instructions can significantly impact decisions made during medical emergencies.

Finally, neglecting to review or update the directive periodically can lead to misalignments with an individual’s current values or beliefs. Life circumstances, medical advancements, and personal insights can change over time. Regularly reviewing the AHCD ensures that it reflects the individual's most recent wishes and preferences.

Documents used along the form

The California Advanced Health Care Directive form is an important document that allows individuals to make decisions about their medical care in advance. It designates a person to make health care decisions on one's behalf if they are unable to do so. Several other documents complement this form, providing additional clarity about health care choices and end-of-life preferences.

  • Durable Power of Attorney for Health Care: This document allows individuals to appoint an agent to make health care decisions on their behalf, similar to the Advanced Health Care Directive. It is often used for broader medical decision-making authority.
  • Living Will: A living will outlines an individual's preferences regarding medical treatments and life-sustaining procedures in scenarios where they may become incapacitated. It serves as a directive for health care providers.
  • Do Not Resuscitate (DNR) Order: A DNR order is a specific directive that instructs medical personnel not to perform CPR or other resuscitative measures in the event of cardiac arrest. It is a critical document for those who wish to decline such interventions.
  • Physician Orders for Life-Sustaining Treatment (POLST): This medical order complements advance directives by translating an individual’s treatment preferences into actionable orders for emergency personnel and health care providers.
  • Organ Donation Form: This form allows individuals to express their wishes regarding the donation of their organs and tissues after death. It can be included with advance directives to clarify intentions on this critical issue.

These documents work together to ensure that an individual's medical desires are honored, particularly during times of incapacitation. Having these forms in place can significantly ease the decision-making process for both the individual and their loved ones.

Similar forms

  • Durable Power of Attorney for Health Care: This document allows individuals to designate a trusted person to make medical decisions on their behalf if they become incapacitated. Like the Advanced Health Care Directive, it focuses on ensuring that a person’s healthcare wishes are honored when they cannot communicate them themselves.
  • Living Will: A living will outlines a person’s preferences for medical treatment in situations where they may be unable to express their wishes, such as terminal illness or irreversible conditions. Similar to the Advanced Health Care Directive, it serves to indicate specific treatment desires at the end of life.
  • Do Not Resuscitate (DNR) Order: This medical order instructs healthcare providers not to perform CPR if a patient’s breathing or heartbeat stops. While the Advanced Health Care Directive encompasses broader healthcare decisions, a DNR specifically targets the desire to avoid life-sustaining measures.
  • Physician Orders for Life-Sustaining Treatment (POLST): The POLST form translates an individual’s healthcare wishes into actionable medical orders that are recognized across different care settings. While the Advanced Health Care Directive establishes general preferences, the POLST provides immediate, concrete instructions for healthcare providers to follow in critical situations.

Dos and Don'ts

When considering the California Advanced Health Care Directive form, it is crucial to approach the task thoughtfully. Here are some things to keep in mind as you navigate this important legal document.

  • Do take the time to fully understand the purpose of the Advanced Health Care Directive. It serves to outline your medical preferences when you are unable to communicate those wishes.
  • Do discuss your health care wishes with your loved ones before filling out the form. Open dialogue can lead to better understanding and support.
  • Do choose a health care agent who is trustworthy and willing to honor your wishes. This person will make decisions on your behalf if you are unable to do so.
  • Do be as specific as possible when detailing your health care preferences. Clear instructions will help guide your agent and health care providers.
  • Do review the form carefully for accuracy once completed. Mistakes can lead to misunderstandings about your care.
  • Don't rush through the process. This document is significant, and taking your time to consider your choices is important.
  • Don't overlook the need for witnesses or notarization if required. Failure to follow these steps may render the directive invalid.
  • Don't assume that verbal agreements will be enough. Written directions carry more weight in medical settings.
  • Don't ignore changes in your health status. Revisiting your directive periodically ensures that it reflects your current preferences.

By keeping these points in mind, individuals can ensure they create an Advanced Health Care Directive that truly reflects their wishes while providing clarity and guidance for their loved ones.

Misconceptions

  • Misconception 1: The directive only applies to end-of-life decisions.

    This is not correct. The California Advanced Health Care Directive can also address treatment preferences for circumstances not necessarily related to end-of-life situations, such as serious illness or incapacity.

  • Misconception 2: You can only create a directive when you are very ill.

    Many people prepare these directives while they are healthy. It’s a proactive way to communicate your wishes in case you become unable to make decisions later.

  • Misconception 3: A doctor can ignore your wishes if they feel otherwise.

    Health care providers are required to follow the instructions specified in your directive, provided these are clear and legal.

  • Misconception 4: You need an attorney to complete the form.

  • Misconception 5: Your choices cannot be changed after the directive is signed.

    You can update or revoke your directive at any time. It’s recommended to review it periodically to ensure it reflects current wishes.

  • Misconception 6: Only one person can be designated as an agent.

    You can appoint more than one person as your agent to make decisions on your behalf. It is a good idea to name an alternate in case your first choice is unavailable.

  • Misconception 7: The form is difficult to understand.

    The California Advanced Health Care Directive is designed to be clear and straightforward. It includes explanations of different sections to help you fill it out correctly.

  • Misconception 8: You must fill out every section of the form.

    While all sections are important, you are not required to complete every part. Focus on the sections that are most relevant to your preferences.

  • Misconception 9: The directive is only for older adults.

    Anyone at any age can create an Advanced Health Care Directive. It is a useful tool for people of all ages to communicate their health care preferences.

Key takeaways

The California Advanced Health Care Directive form is a vital tool for individuals wishing to express their medical preferences ahead of time. Here are key takeaways on how to fill it out and utilize it effectively:

  1. Understand the Form: Familiarize yourself with the purpose of the directive, which allows you to outline your healthcare decisions and appoint someone to make those decisions on your behalf if you become unable to communicate.
  2. Choose Your Agent Wisely: Select a trusted individual to act as your healthcare agent. This person will be responsible for making medical decisions based on your wishes and values.
  3. Be Clear and Specific: Clearly articulate your wishes regarding life-sustaining treatments and other medical interventions. Avoid vague language to ensure your preferences are understood.
  4. Discuss with Loved Ones: Have open conversations with family and friends about your healthcare preferences. This ensures everyone is aware of your choices and can support your agent in making decisions.
  5. Keep It Accessible: Make sure copies of your completed directive are easily accessible to your healthcare agent, primary care physician, and hospital. Regularly review and update the form as needed.

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