Advance Health Care Directive (California Probate Code §4701)
I, [Your full name], born [Your date of birth], residing at [Your address], make this Advance Health Care Directive. You have the right to give instructions about your own health care and to name another person to make health care decisions for you. This form lets you do either or both. If you use this form, you may complete or modify all or any part of it, and you are free to use a different form. Part 1 lets you name a health care agent. Part 2 lets you give specific instructions. Part 3 lets you express wishes about organ donation. Part 4 lets you name your primary physician. Sign and date the form at the end and have it witnessed by two qualified adults, or acknowledged before a notary public. Give a copy to your agent, your alternates, your physician and any health care institution where you receive care.
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: [Health care agent: name], of [Agent: address], telephone [Agent: phone]. 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: [First alternate agent: name], telephone [First alternate: phone]. If my first alternate is also not willing, able or reasonably available, I designate as my second alternate agent: [Second alternate agent: name (or "None")], telephone [Second alternate: 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: [Limits on your agent’s authority (or "None")].
1.3 When agent’s authority becomes effective. My agent’s authority becomes effective: [When your agent’s authority takes effect].
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 make anatomical gifts, 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 willing, 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 here: [End-of-life decision]. The two choices mean the following. 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. 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: [Relief from pain].
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: [Other wishes (or "None")].
Part 3. Donation of Organs at Death
Upon my death, my instruction regarding donation of my organs, tissues or parts is: [Organ donation]. Limits, or the purposes for which a gift may be used (transplant, therapy, research or education): [Donation: limits or purposes (or "None")]. If I have not limited the purposes, my gift is for any of them.
Part 4. Primary Physician
I designate the following physician as my primary physician: [Primary physician: name], telephone [Primary physician: phone]. If that physician is not willing, able or reasonably available to act as my primary physician, my agent may designate one in consultation with my other health care providers.
Part 5. Effect of Copy; Signature
5.1 Effect of copy. A copy of this form has the same effect as the original.
5.2 Signature. I sign my name to this Advance Health Care Directive on the date shown in the execution record. My address is stated above.
5.3 Statement of witnesses. Each witness, by signing below, declares 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.
5.4 Additional statement of witnesses. At least one of the witnesses, by signing below, further declares 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.
First witness: [First witness: name], of [First witness: address]. Second witness: [Second witness: name], of [Second witness: address].
5.5 Special witness requirement. If you are a patient in a skilled nursing facility, the patient advocate or ombudsman must sign the following statement: 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.
Signatures
Principal (the person this directive is for) · First witness · Second witness