PROBATE CODE
SECTION 4700-4701
4700. The form provided in Section 4701 may, but need not, be used
to create an advance health care directive. The other sections of
this division govern the effect of the form or any other writing used
to create an advance health care directive. An individual may
complete or modify all or any part of the form in Section 4701.
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) Make anatomical gifts, 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 and tissues 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.
* * * * * * * * * * * * * * * * *
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.
(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:
______________________________________________________________________
____
______________________________________________________________________
____
______________________________________________________________________
____
(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 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 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.)
PART 3
DONATION OF ORGANS AT DEATH
(OPTIONAL)
(3.1) Upon my death (mark applicable box):
_
|_| (a) I give any needed organs, tissues, or parts, OR
_
|_| (b) I give the following organs, tissues, or parts only.
_____________________________________________________________________
(c) My gift is for the following purposes (strike any of the
following you do not want):
(1) Transplant
(2) Therapy
(3) Research
(4) Education
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)
* * * * * * * * * * * * * * * * *
PART 5
(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
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) (print name)
______________________________
____________________________________
(address) (address)
______________________________
____________________________________
(city) (state) (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)
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)