The Advance Health Care Directive

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Click here to review some Frequently Asked Questions about the Advance Health Care Directive.

About the Advance Health Care Directive

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. The form from this page lets you do either or both of these things. It also lets you express your wishes regarding donation of organs. You may complete or modify all or any part of this form. 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, to your health insurance company, 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 on this responsibility. You have the right to revoke this advance health care directive or replace this form at any time.

Click here for more information about the Advance Health Care Directive from the California Medical Association.

Completing the Form

PART 1: POWER OF ATTORNEY FOR HEALTH CARE

Designation of Health Care Agent

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. You may also name alternate agents 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 you 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.)

Authority of Agent

Unless you limit the authority of your agent on this form, 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. Nothing in this form authorizes your agent under this Power of Attorney for Health Care to make a health care decision if you object to the decision. If you object to the health care decision of the agent under this Power of Attorney for Health Care, the matter will be governed by the law that would apply if there were no power of attorney for health care.

Agent’s Postdeath Authority

This part of the form lets you express an intention to donate your bodily organs and tissues following your death.

PART 2: INDIVIDUAL HEALTH CARE INSTRUCTION

Part 2 of this form lets you give specific instructions about any aspect of your health care, whether or not you appoint an agent. 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. 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 artificial nutrition (food), hydration (water), and 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 necessary, you may attach additional sheets for this purpose.

PART 3: MISCELLANEOUS PROVSIONS AND EXECUTION

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. Each witness signing the advance directive shall witness either the signing of the advance directive by the patient or the patient's acknowledgment of the signature or the advance directive. A “qualified witness” is an adult and cannot be any of the following:

  • Your health care provider or an employee of your health care provider;
  • The operator or an employee of a community care facility;
  • The operator or an employee of a residential care facility for the elderly; or
  • The person you named as your agent in Part 1 of this form.

Special Witness Requirement

In addition to the limitations above, at least one of the witnesses shall be an individual who is neither related to you by blood, marriage, or adoption, nor entitled to any portion of your estate upon the your death under a will or trust existing when this form is signed.

Statement of Patient Advocate or Ombudsman

If you are a patient in a skilled nursing facility when this form is signed, this advance health care directive is not effective unless a patient advocate or ombudsman signs the advance directive as a witness. This is a requirement even if this form is notarized.

Certificate of Acknowledgement of Notary Public

Notarization is only necessary if qualified witnesses are not available or if you prefer notarization instead of witnesses.

If you have any questions about how to complete this form, please call META law, inc. at (805)856-3400.