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California Advance Health Care Directive Form | POA & Living Will

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California Advance Health Care Directive Form (POA & Living Will), allows an individual to choose an agent to make healthcare decisions on his or her behalf in the event they can no longer make them. When a person is considered incapacitated, they no longer are able to make decisions for themselves. This can be due to a number of reasons mostly involving dementia, Alzheimer’s Disease, and any other illness that incapacitates the patient. This allows the individual to also specify certain treatment preferences in the event that he or she cannot communicate decisions at the time.

Laws – Probate Code Section 4701


Durable (Financial) Power of Attorney – This POA can be employed to list a friend, family member, or other trusted individual to assist you in taking care of your financials once you are incapacitated.

How to Write

Download: Adobe PDF, Microsoft Word (.docx) or Open Document Text (.odt)

Step 1 – Access Then Save This California Document To Appoint A Health Care Agent

You may download a copy of the “Advance Health Care Directive,” which is in compliance with “California Probate Code Section 4701” by selecting the “PDF,” “Word,” or “ODT” buttons included on this page with the preview image.

 

Step 2 – Formally Name A Specific Person To The Health Care Agent Role

Once you’ve obtained this document, read the beginning, then  locate the heading “Part 1 Power Of Attorney For Health Care.” This section will present the language needed to appoint an individual of your choice with the right to make certain medical decisions on your behalf when you are unable to do so or under your direction. Notice the item label “(1.1) Designation Of Agent.” This statement will declare who will be able to wield (representative) Health Care Powers with your approval and authority but will need the full name of the determined Health Care Agent furnished on the first blank line.   Three more empty lines, each labeled, follow the name you just entered. These will also refer to the Health Care Agent you are designating and require his or her official “Address,” “City,” “State,” and “Zip Code” produced for display. Make certain this is where the Health Care Agent maintains his or her residence. In addition to the name and home address of the Health Care Agent, it is important that we also deliver his or her telephone numbers. Two blank lines “Home Phone” and “Work Phone” are provided for this purpose. You may also insert another to deliver additional numbers such as the Health Care Agent’s cell phone number. Whoever reviews this document may find it imperative to reach your Health Care Agent immediately.

 

Step 3 – Support The Health Care Agent Role With Alternative Designations

This document will consider the consequences of the Health Care Agent above becoming unable, unwilling, or no longer authorized to carry out the directives and duties that come with the powers you are granting. The next statement in this article, labeled with the capital word “Optional,” supplies an area similar to the one above where you may designate an Alternate Health Care Agent to assume and use the representational authority granted by the Health Care Agent role. To be clear, so long as the Health Care Agent named above retains your approval and authority, the Alternate Health Care Agent will be unable to wield any decision-making powers in your name. The Alternate Health Care Agent will only exist as a back-up so long as you enter his or her name on the first blank space in the “Optional” paragraph discussed. Then record his or her “Address,” “City,” “State,” “Zip Code,” “Home Phone” number, and “Work Phone” number on the blank lines provided after the Alternate Health Care Agent’s name. The next “Optional” paragraph functions like the one we just attended. However, here you can name a Second Alternate Health Care Agent should both the previous Agents you named have their powers revoked (by you) or are otherwise unable to represent you. This section will need a report on the Second Alternate Health Care Agent’s name, complete address, home telephone and work telephone numbers documented on the appropriately labeled blank lines. This entity’s power will only be assumed in a successive fashion so that, he or she will only be able to make decisions and act in your name should the Health Care Agent and Alternate Health Care Agent have their powers removed or revoked.

 

Step 4 – Convey All Exceptions To The Health Care Agent’s Powers

As we continue through the first article to “1.2 Agent’s Authority” a brief discussion to solidify the Health Care Agent’s right to engage health care decisions and actions with your authority is presented. You may list specific exceptions to these powers by providing a discussion on what health care powers you do not authorize the Agent to use in your name. For instance, you may wish to restrict the Health Care Agent’s ability to decide if you must be put on dialysis should it become necessary while you are in a coma.

 

Step 5 – Document The Post-Death Decisions And Actions Barred From Your Agent

The Health Care Agent, unfortunately, may be presented with a few post-death decisions that need to be made either while you are incapacitated or after life has ended. In “1.5 Agent’s Post Death Authority,” a description of actions your Agent may take in this matter is presented. If any part of this statement is untrue you may cross it out. If this statement is true but you wish to bar the Health Care Agent’s powers from acting in certain areas, you may do so by reporting this on the blank lines in this paragraph.

 

Step 6 – Indicate Whether You Wish Your Life Prolonged

You may have designated a Health Care Agent to represent you in the State of California should you become unable to communicate with Medical Personnel or you may have left Part I unattended. “Part 2 Instructions For Health Care” is meant to be a direct dialogue between you and any Medical Personnel attending your care. If you did appoint a Health Care Agent, you still have the option of documenting such directives in Part 2. This will deal mainly with an end-of-life event where decisions on prolonging your life become necessary. In the paragraph “2.1 End-Of-Life Decisions,” one of two checkbox statements should be marked to indicate which represents the policy you wish used in such a scenario. Thus, if you are rendered unable to communicate, you are in a situation where you have an “…Incurable And Irreversible Condition…,” are in a permanent vegetative state, or face risking a dangerous or burdensome treatment (i.e. chemotherapy), then you should mark the first box “(A) Choice Not To Prolong Life” to prevent Medical Personnel or your Health Care Agent from prolonging your life against your wishes. If you wish your life prolonged by applying whatever (legal) medical treatment or intervention necessary, mark the second checkbox “(B) Choice To Prolong Life”

 

Step 7 – Deliver Your Policy On Pain Management

As a standard, medical treatment will often incorporate pain management to maintain a certain quality of life for the concerned patient. During an end-of-life event, this may cause some conflicts with your preferences or beliefs. Thus, if there are any considerations that require medical personnel to withdraw efforts to relieve pain, you must state them plainly on the blank lines in “2.2 Relief From Pain.” 

 

Step 8 – Address Additional Topics Regarding An End Of Life Event

We have discussed your directives concerning treatments and interventions necessary to prolong your life and manage pain. If additional considerations should be made according to your beliefs or directives, then you may record them in “(2.3) Other Wishes.”   

 

Step 9 – Decide Then Report Your Post-Death Wishes

Some post-death decisions can be made in “Part 3 Donation Of Organs, Tissues, And Parts At Death (Optional).” If you will donate your organs, tissues, and body parts and authorize your “Agent To Consent To Any Temporary Medical Procedure Necessary Solely To Evaluate” these donations, then mark the checkbox corresponding to the words “Upon My Death” and the label “(3.1)”If you have opted to make post-mortem organ/tissue donations, you may object to a specific purpose. Simply review the list provided and strike out any purpose you will not support with such a donation. There is also enough room to list specific restrictions by reporting them on the blank lines attached to the statement “If You Want To Restrict Your Donation…”

 

Step 10 – Record Your Primary Physician’s Information

If you have a Primary Physician that you wish informed during a traumatic medical or end-of-life event, then you have the option of producing his or her contact information for any concerned and involved Medical Personnel reviewing this document using “Part 4 Primary Physician (Optional).” Start this section by entering your Physician’s full name on the blank line attached to the “Name Of Physician” label. After reporting this identity, you must produce your Primary Physician’s office or practice’s mailing address utilizing the four lines (“Address,” “City,” “State,” “Zip Code”) to do so.  Finally, the “Phone” line in this section expects the current contact number your Primary Physician wishes used by the public or the Medical Personnel reviewing this directive.  Notice that an additional “Optional” paragraph is provided. Here, you may name an Alternate Primary Physician. This should be a Physician that you believe is comparable to the one above regarding your medical history and any current medical conditions you suffer through. The Alternate Primary Physician will be the next professional contacted should the Primary Physician be unavailable. A blank space for the “Name Of Physician,” and his or her “Address,” “City,” “State,” and “ZIP Code” are available for your report as well as a line for his or her “Phone” number. You may leave this section blank at your discretion or add more physicians through an attachment.

 

Step 11 – Properly Appoint Your Agent By Executing Your Signature

“Part 5” shall allow you to finalize this document so you may submit it to the proper medical facilities concerned with your care. This will involve a signing before two witnesses or a Notary Public. Thus, gather these individuals to one place then proceed to enter the current “Date” on the first available line underneath the section label “(5.2) Signature.”After you have reported the current calendar day, signed your name, and printed your name,”  report your address using the blank spaces attached to the “Address,” “City,” and “State” labels. The two Witnesses who have observed your act of signing will each have a distinct section (“First Witness” and “Second Witness”) to verify the successful signing. As with the Principal (You) Signature each Witness must tend to a unique section by submitting the current “Date,” his or her name (signed and printed), and his or her address. Section “(5.4) Additional Statement Of Witnesses” requires at least one Witness to verify that he or she is not related to you “By Blood, Marriage, Or Adoption” and has no belief of being or expectation of being entitled to any of your property or assets after death. This testimony will provide a “First Witness” and “Second Witness” signature areas. If this statement is true for both Witnesses, they are both encouraged to fill in his or her respective signature area with the “Date” of his or her signature along with his or her signature, printed name, and address.    If you require skilled nursing or supportive care and are a patient of a skilled nursing facility the “Statement Of Patient Advocate Or Ombudsman” must be completed. Only a Patient Advocate or Ombudsman may act as this Special Witness by providing the signature “Date,” signature, printed name, and address required by this entity. This requirement serves to protect your rights in the nursing facility caring. 


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