Advance Health Care Directive Instructions

ADVANCE HEALTH CARE DIRECTIVE INSTRUCTIONS

This Advance Health Care Directive (the “Directive”) is compliant with the CALIFORNIA PROBATE CODE SECTION 4700-4701 (the “Code”).

Under the Code you have the right to make decisions about how healthcare is administered to you.

You also have the right name a person, or people (who are called your Agent(s)) who can make decisions about your health care on your behalf.

This Directive allows you to record your decisions and choose your Agent as well as expressing your wishes regarding donation of organs and to choose who your primary or alternate physician is.

When you complete this form, you are advised that you may not regard this form as completed with the assistance of an attorney.

PART 1 INSTRUCTIONS

This part of the Directive is a power of attorney for health care. It is not necessary for you to complete this section if you do not want to appoint someone to make decisions for you and simply want to provide instructions to those treating you as to how you would like your health care administered.

1. This part lets you choose who your Agent is to be who will make decisions for you. You may also name an alternate Agent if your first choice is not willing or available or is themselves not capable of making decisions on your behalf. You can choose as many alternative Agents as you wish although you do not have to choose any alternative Agents if you do not want to.

PLEASE NOTE: Your Agent can 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 co-worker.

2. You have the option in this form to limit the types of decisions about your health care that your Agent can make for you. You do not have to limit the authority of your Agent but if you choose not to, 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; and

(e) Make anatomical gifts, authorize an autopsy, and direct the disposition of your remains.

Limit the authority of your agent by writing what decisions you don’t wish them to take in the space provided under Point 2.

3. You can also choose the time at which your Agent can make decisions for you. This is either

(i)  only if you become incapable of making your own decisions as certified by your physician; or

(ii) if you decide that you want your Agent to make those decisions even if you are still mentally capable of doing so - in this case you should choose the immediate option.

4. Your Agent is obliged to make decisions on your behalf with your best interests in mind.

5. You can also decide to give your Agent authority to make decisions about what happens to your body after you die subject to your statements in Part 3 of the form and any other restrictions outlined in the form. This is however optional and if you don’t want to give them this authority please cross out and initial Point 5.

6. You also have the option of nominating your Agent to be a Conservator during your lifetime. A Conservator is a person or organization who is appointed by the court,to care for another adult (called the “conservatee”) who cannot care for himself or herself or manage his or her own finances. This is however optional and if you don’t want to give them this authority please cross out and initial Paragraph 6.

7. You also have the option to give your Agent the authority to sign forms under HIPAA (Health Insurance Portability and Accountability Act) that allows the release of your medical records if necessary. This is however optional and if you don’t want to give them this authority please cross out and initial Paragraph 7.

PART 2

INSTRUCTIONS

Part 2 of this form allows you to give specific instructions about how any aspect of your health care is handled, whether or not you appoint an agent.

8. You can choose either not to prolong your life by initialling the box at A. You have the option of deciding in what three circumstances you would consider not prolonging your life. Please initial all boxes that apply to you.

Alternatively you may initial the box at B if you want your life prolonged for as long as medically possible.

9. You can choose regardless of your choice at Paragraph 8 to continue to be provided with artificial nutrition and hydration by ticking the box in this Paragraph.

10. Pain relief will be administered in all situations other than those you enter in the space provided below this paragraph.

PART 3

INSTRUCTIONS

Part 3 of this directive gives you the choice of whether you wish to donate any organs or none at all. You can also specify any organs you don’t wish to donate. Please initial the box that best applies to your wishes.

You are also given the opportunity to decide what purposes any donated organs are put to. Initial all the boxes that you would be happy for your organs to be used for.

PART 4

INSTRUCTIONS

Part 4 of this directive lets you designate a physician to have primary responsibility for your health care.

You also have the option to select an alternate physician if yours is unable or unwilling to look after your health care

In the event you do not choose a primary physician then a physician will be chosen for you under the California Medical Association rules.

PART 5

INSTRUCTIONS

This Directive must be signed correctly in order for it to be valid. You have two options as follows:

(A) OPTION 1 - WITNESS

Signed by two (2) qualified adult witnesses who are personally known to you or to whom you have proven your identity by convincing evidence and who are present when you sign or acknowledge your signature. Your witnesses may not be

(1)  your health care provider or an employee of your health care provider,

(2)   the operator or an employee of a community care facility,

(3)  the operator or an employee of a residential care facility for the elderly, or

(4)  the person you have appointed as an agent, if you have appointed an agent.

In addition, one of your witnesses must be unrelated to you by blood, marriage, or adoption and not entitled to any portion of your estate.

OR

(B) OPTION 2 - NOTARY

Witnessed by a notary.

A full list of notaries can be found at http://www.sos.ca.gov/notary/notary-public-listing/

PLEASE NOTE: If you are a patient in a skilled nursing facility when you execute your advance directive, Part 6 must be signed and completed by a patient advocate or ombudsman. This person must sign the statement at Part 6, even if you have had your advance directive notarized under option 2. If you choose option 1 this person must also sign as one of your witnesses under option 1.

ADVANCE HEALTH CARE DIRECTIVE

PART 1

POWER OF ATTORNEY FOR HEALTH CARE

1. AGENT.

I, [Enter Name], of [Enter Address in California], do hereby designate the following individual as My Agent to make healthcare decisions for me:

Agent:

Name:    [Enter Name of Agent]

Address:   [Enter Address - does not have to be in California]

Phone:    Home: [Phone Number] Work: [Phone Number]

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 [OPTIONAL]:

Name:    [Enter Name of Agent]

Address:   [Enter Address - does not have to be in California]

Phone:    Home: [Phone Number] Work: [Phone Number]

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:

Second Alternate [OPTIONAL]:

Name:    [Enter Name of Agent]

Address:   [Enter Address - does not have to be in California]

Phone:    Home: [Phone Number] Work: [Phone Number]

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:

[Enter any restrictions you wish to place on your Agent]

3. WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE. My agent's authority becomes effective [choose one of A or B]

(a)  if I mark the box here [     ] then immediately

(b)  if I mark the box here [      ] the when my primary physician determines that I am unable to make my own health care decisions.

4. AGENT'S OBLIGATION. My agent shall make healthcare 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 healthcare 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.  

[YOU MAY CROSS OUT AND INITIAL ANY STATEMENTS IN THIS PARAGRAPH THAT YOU DO NOT AGREE WITH]

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, in paragraph (2) above, or in Part 3 of this form:

(Attach additional sheets if needed)

[YOU MAY CROSS OUT AND INITIAL ANY STATEMENTS IN THIS PARAGRAPH THAT YOU DO NOT AGREE WITH]

6. NOMINATION OF GUARDIAN OR CONSERVATOR. If a guardian or conservator of my person or estate or both, 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 guardian or conservator, I nominate the alternate agents whom I have named, in the order designated.   [YOU MAY CROSS OUT AND INITIAL ANY STATEMENTS IN THIS PARAGRAPH THAT YOU DO NOT AGREE WITH].

7. HIPAA With this document I authorize my agent to sign all forms required under HIPAA that refer but are not limited to the release of my medical records.

PART 2

INSTRUCTIONS FOR HEALTH CARE

[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 THIS PART OF THE FORM.]

8. 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 initialed below [INITIAL ONE OPTION FROM A or B BELOW]:

[ ]   A. CHOICE NOT TO PROLONG LIFE. I do not want my life to be prolonged if [INITIAL ALL STATEMENTS YOU AGREE WITH]:

[ ] i. I have an incurable and irreversible condition that will result in my death within a relatively short time

[ ] ii.  I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness

[ ] iii the likely risks and burdens of treatment would outweigh the expected benefits

[ ]   B. CHOICE TO PROLONG LIFE. I want my life to be prolonged as long as possible within the limits of generally accepted healthcare standards.

9. ARTIFICIAL NUTRITION AND HYDRATION. Artificial nutrition and hydration must be provided, withheld or withdrawn in accordance with the choice I have made in paragraph 8 unless I initial the following line.

[ ] If I initial this box, artificial nutrition and hydration must be provided regardless of my condition and regardless of the choice I have made in paragraph 8

10. 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:

(Attach additional sheets if needed)

11. 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:

(Attach additional sheets if needed)

PART 3

DONATION OF ORGANS AT DEATH

12. Upon my death: [INITIAL THE STATEMENT THAT MATCHES YOUR WISHES]

[   ] (a) I do not give any of my organs, tissues, or parts and do not want my agent, conservator, or family to make a donation on my behalf; OR

[   ] (b) I give any needed organs, tissues, or parts; OR

[   ] (c) I give the following organs, tissues, or parts only [WRITE IN THE SPACE BELOW]

(Attach additional sheets if needed)

13. My gift is for the following purposes: [INITIAL ALL THOSE REASONS YOU ARE HAPPY FOR YOUR ORGANS, TISSUES OR PARTS TO BE USED FOR]

[   ]  (1) Transplant

[   ]  (2) Therapy

[   ]  (3) Research

[   ]  (4) Education

PART 4

PRIMARY PHYSICIAN

14. I designate the following physician as my primary physician:

Physician:

Name:                                                                            [Enter Name of Physician]

Address:                                                               [Enter Address of Physician]

Phone:                                              [Enter Phone number of Physician]

15. 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:

Alternate Physician:

Name:                                                                            [Enter Name of Physician]

Address:                                                          [Enter Address of Physician]

Phone:                                            [Enter Phone number of Physician]

16. If a primary physician is not selected under part 4, then I request that the rules of California Medical Association be applied for the identification of my primary physician.

PART 5

17. EFFECT OF COPY. A copy of this form has the same effect as the original.

18. SIGNATURE.

[CHOOSE ONE OPTION OF THE FOLLOWING 2]

PLEASE NOTE: If you are a patient in a skilled nursing facility when you execute your advance directive, Part 6 must be signed and completed by a patient advocate or ombudsman. This person must sign the statement at Part 6, even if you have had your advance directive notarized under option 2. If you choose option 1 this person must also sign as one of your witnesses under option 1.

OPTION 1 - WITNESS

Declarant Signature: _______________________________________

__________________________    

(date)

__________________________________________________________

(printed name)

__________________________________________________________

__________________________________________________________

(address including city, state and Zip)

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 an 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:        

Witness Signature:   _______________________________________

__________________________    

(date)

__________________________________________________________

(printed name)

__________________________________________________________

__________________________________________________________

(address including city, state and Zip)

Second Witness:  

Witness Signature:   _______________________________________

__________________________    

(date)

__________________________________________________________

(printed name)

__________________________________________________________

__________________________________________________________

(address including city, state and Zip)

OPTION 2 - NOTARY

A notary public or other officer completing this certificate verifies only the identity of the individual(s) who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

Declarant Signature: _______________________________________

__________________________    

(date)

__________________________________________________________

(printed name)

__________________________________________________________

__________________________________________________________

(address including city, state and Zip)

STATE OF CALIFORNIA, COUNTY OF _________________________

On __________________ before me, ___________________________________, personally appeared                                                               [ENTER YOUR NAME], 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.

________________________________________ (Notary Seal)

Signature of Notary Public

PART 6 - SPECIAL WITNESS REQUIREMENT.

16. 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.

       

Witness Signature:   _______________________________________

__________________________    

(date)

__________________________________________________________

(printed name)

__________________________________________________________

__________________________________________________________

(address including city, state and Zip)