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California Advanced Health Care Directive Form | POA & Living Will

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The California Medical Power Of Attorney And Living Will, which is also known as the “California Advance Health Care Directive”, allows an individual to choose an agent to make healthcare decisions on his or her behalf in the event he or she cannot. This allows the individual to also specify certain treatment preferences in the event that he or she cannot communicate decisions at the time.

The statute under which this document is allowed is California Probate Code Sections 4700 to 4701. This is an important document that allows you to specify ahead of time, that person that you want to make health decisions for you if you are unable to. If you do not have such a plan in place, decisions may be made by others who do not know your wishes.

Durable 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 your incapacitated.

How to Write

1 – Download the California Advance Health Care Directive

This form is accessible using the buttons below the preview file image on the right. You may fill in the information with a form friendly browser or save it then open it with a compatible software program to edit or fill in the information. In the absence of such software, you may also print this form then fill it out manually. If there is not enough room in any of the sections, you may continue reporting the Principal instructions on another sheet of paper then attaching it. If there are any statements the Principal does not wish included, he or she may cross out such statements then initial the strike trough.

2 – Part I Designation of Agent

Locate Item 1.1, then on the blank space labeled “name of individual you choose as agent,” report the Full Name of the individual who shall serve as the Principal’s Health Care Agent.

Report the Agent’s Address of Residence as it appears on his or her Identification papers using the blank space with the labels “address,’ “city,” “state,” and “Zip Code”

Use the blank line with the labels “home phone” and “work phone” and report the Health Care Agent’s Telephone Numbers

The next paragraph will have some areas requiring information, however, this will be considered optional. In some cases, the Principal wishes to take an extra precaution by setting up a Successor or Alternate Agent to step into the Primary Health Care Agent role should the Primary Health Care Agent be unable to perform his or her duties or the Principal revokes his or her power. The Principal of this document may name such an entity in the paragraph labeled “Optional”

The Contact Information for the first Alternate Agent should also be reported. Use the next blank line to report the Alternate Agent’s Address by entering its components in the appropriately labeled areas

 

The first Alternate Agent’s Home Phone Number and Work Phone Number will also need to be recorded. These must be telephone numbers where this party may be easily and reliably reached.

Locate the blank space labeled “name of individual you choose as second alternate agent,” then enter the Full Name of the Successor or Alternate Agent on this space. Next, enter the Residential Address of the Successor or Alternate Agent on the blank line divided by the areas labeled “address,” “city,” “state,” and ‘Zip Code.”Enter the Successor or Alternate Agent’s Telephone Number both at Home and in his or her place of Employment on the blank space (above the words “home telephone” and “work phone”).

 

 

3 – The Agent’s Authority

Use the blank lines in Item 1.2 to document restrictions pertaining to the Health Care Agent’s Decision Making Authority.

4 – The Period of Effect’s Start Date

Item 1.3 will declare the Start Date of the Health Care Agent’s Authority as the Date a physician declares the Principal is unable to make decisions or the Principal becomes incapacitated. However, if the Principal wishes the Date of Effect to begin immediately after signing then he or she must mark the box following the words “If I mark this box…” If this box is left unmarked the default Date of Effect will be determined in the future by the Principal Physician’s Diagnosis at the time.

5 – Anatomical Gifts

Locate Item 1.5. If the Health Care Agent will have Post Death Authority and may make Anatomical Gifts on behalf of the Principal, this item will give the opportunity to place limitations or restrictions regarding the Anatomical Gifts and the Circumstances for Donating them. (This will also be addressed in Part III).

6 – Part II Principal Health Care Instructions

The Principal will need to indicate several facts of preference under the heading “Part 2 Instructions For Health Care” To begin, locate Item 2.1 or “End-of-Life Decisions.” The Principal must mark one of three options to indicate his or her stance when it comes to prolonging life.

If the Principal does not wish to prolong his or her life in cases where he or she is terminal, goes into a coma, or the burdens of treatment outweigh the benefits, then mark the box preceding the choice “(a) Choice Not To Prolong Life”

If the Principal wishes to prolong his or her life in the face of such circumstances so long as it is within limits of Health Care Standards, then he or she should mark “(b) Choice to Prolong Life”

7 – Pain Management

Locate Item 2.2, “Relief From Pain.” By default, this form’s directive will expect that relief from pain or discomfort is provided at the time of death. If the Principal wishes to put restrictions upon this instruction, then he or she may do so by entering it on the two blank lines provided in Item 2.2.

8 – Additional Instructions

Locate Item 2.3, “Other Wishes,” then report any further instructions, restrictions, or extensions to the Health Care Agent powers listed in this document. If necessary, you may continue this report on a separate sheet of paper that is clearly titled and signed.

9 – Optional Instructions

The next page will begin with the “Optional” section. Here, the Principal may further and quickly define some specifics to this document. To begin locate Item 3.1 as this will provide several optional statements regarding the Principal’s Post-Death wishes and Anatomical Gifts

If the Principal will give whatever is needed as an Anatomical Gift, then select the first bubble “(a)”

If the Principal will only give certain Anatomical Gifts, then mark the second bubble “(b)” and list these organs/tissues/etc. on the blank line provided

Next, the next statement, “(c) My gift…,” will list the various purposes an Anatomical Gift can be made for. The Principal may strike out any purpose he or she will not make an Anatomical Donation for.

10 – Part IV Naming The Primary Physician

If desired the Principal may name his or her Primary Physician. This part is optional, however, may prove useful if filled out.

Locate Item 4.1 then, on the blank line labeled “name of physician,” enter the name of the Principal’s Primary Physician. On the next line, the Primary Physician’s Address should be reported on the blank line below the Name. Finally, report the Primary Physician’s Contact Telephone Number.

The next paragraph, labeled “Optional,” will provide an opportunity to list an alternate Primary Physician in the event the one listed above is reasonably unavailable. Here there will also be three blank lines where you may report the alternate Primary Physician’s Name, Address, and Contact Telephone Number.

11 – Part 5 Principal and Witness Signature Statements

Locate Part 5 then, in Item 5.2, the Principal must enter the Signature Date then Sign his or her Name on the blank spaces labeled “date” and “sign your name” (respectively).

The top of the next page will continue Principal Verification as the Principal must also provide his or her Address and Printed Name on the appropriate blank spaces.

Item 5.3, or “Statement of Witnesses,” will contain a Witness Statement that both Witnesses should read before signing. At the end of this statement will be ample room for each Witness to Print his or her Name, provide his or her Address, Sign his or her Name, and enter the Signature Date.

Item 5.4 (“Additional Statement of Witness”) will require at least one of the Witnesses to read then Sign it. There will be enough room for both Witnesses to sign this statement at the end of it.

If the Principal is a patient in a skilled nursing facility and a special witness (patient advocate or ombudsman) is a required part of the Principal’s supportive care, this party must also Sign and Print his or her Name. In addition, the patient advocate or ombudsman must also provide a Signature Date and his or her Address.


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