California Advance Directive

California government website ^ | 03-22-2005 | California Probate Code

[kralcmot]

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)

[kralcmot]

for those of us in California, its all right here, pasted direcly off the government web page. all we have to do is read the explanation, think about the options, discuss it with our loved ones, choose the witnesses, fill out the appropriate parts of the form for your wishes, and sign it with the witnesses in attendenance, and they must sign it then as well...then copy it and distribute it. i am doing it now. right now, as soon as i post it for you

note especially this "If you use this form, you may complete or modify all or any part of it.

You are free to use a different form."

see lines 8,9, and 10 of this posting

[socal_parrot]

I think this whole situation shows the need for some sort of directive for next-of-kin (not just spouse), be it this sort of form or a living will.

[Shermy]

I think this whole situation shows the need for some sort of directive for next-of-kin (not just spouse),

Spouses shouldn't trump parents? Where does it end?

Anyway, consider if one is pro-Life, how can one sign this pro-choice document? Why should it matter if Terri said she didn't want to be sustained verbally or in writing?

[longtermmemmory]

If it is in writing, and properly executed, there is no reason to doubt it would be upheld.

Then the only challenge would be to show the document is a fake or had been surperceeded by another document (like a new will over an old will)

[Carry_Okie]

Already done.

[ErnBatavia]

Wifey and I both have the "no heroics" form in all of these places:

1 - With our papers at home.
2 - In our files with our M.D.
3 - copies clipped to registration in our vehicles.
4 - copies (shrunk, readable via microfilm reader) in our wallets.

[Shermy]

If it is in writing, and properly executed, there is no reason to doubt it would be upheld.

Since Terri has a constitutional right to life what difference is there if she signed this or a cocktail napkin? Suicide pacts are OK if the party becomes unconscious? This paper, or Terri's verbal wishes, allows, even provokes her guardian and health care provider to be murderers?

[socal_parrot]

My point was that in the Scaivo case, there is no living will so the courts are going with the spouse's wishes. If she would have done a directive things would be more clear.

[longtermmemmory]

You have no understanding of the abortion debate if you confuse apples and oranges. A living will is executed by an adult for themselves to let others know what they want.

In the present debate the mother and father would have a different view if there was a document which said "do this". Same for the judge.

Now we only have a heresay exception statement which was admitted and considered.

[kralcmot]

i think you are asking, "what if my parents want to care for me but my spouse wants me to die?"

the form can be modified in any way, according to the instructions. perhaps you could indicate that you require that your parents and your spouse must all agree on any procedures for you, and that absent such agreement, you wish to be placed in the care of any of them who wants you to live.

[socal_parrot]

If my wife hits me in the head with a rolling pin (a distinct possiblility considering my behavior over the years), and I am in a coma, why would I want my wife to decide my fate?

[longtermmemmory]

You should see what happens when there is a living will and the wife is NOT the person designated to make the decision. There is no rule that says the person has to know they are not the healthcare surrogate OR that the husband even has a living will.

Sometimes it is an innocent reason, I don't want my wife to have to make the choice or I want my brothersistermotherorfather to make the choice because they have "X" qualification. (doctor etc.)

[oreolady]

Careful here, people.
I have mine in another state, but STOP AND THINK WHAT YOU ASK YOUR FAMILY TO ENACT.
I realize they by law have to honor your wishes, even if they disagree , but I decided to keep food/water, yet authorizing "pulling the plug" to any respirator or machine,to NOT SUBJECT MY FAMILY to watching the suffering and ugliness of a dehydration death!
I don't want them to have any guilt, or also to suffer the above mentioned.
So just THINK CAREFULLY your choices.
Also, be warned that this document is subject to change re state laws.
In this death culture, laws are being reworded daily, for example, when Terri Shiavo was admitted at first to the hospital, food/water, was NOT LEGALLY classsified as "life support".
As later enacted, those who had the overly simple words, "life support", legally had to be offed by dehydration method, even if they didn't even think of that possibily, added to laws later than document.

[oreolady]

LOL, what you said!

(says it all)

[kralcmot]

quick, someone notify his wife and make sure he is not allowed to make health care decisions for HER.

[longtermmemmory]

In FL the living will provisions specifically adress the issue of assisted suicide. IF Terri had a living will which said do not feed me, do nto treat me, it is almost a certainty the court would have upheld it as they have in other situations.

What I have seen has been in cancer situations where the treatment was going no where and when the husband or wife makes a decision to let the disease run its course, the mother or father attempt to come in and overide the living will as not being made competently. BUT in those situations there is evidence with the properly executed living will before the person is too far gone.

Every medical situation is unique with unique circumstances.

I personally have very serious concerns when the only "treatment" is food and water. Today it is food and water via a tube, tommorow it may be food and water via any means because you are "unhappy". Then it becomes because you make someone else "unhappy".

There has to be an instrument which people can use to say "if I am hurt or hurting in some way and can not speak, THIS is what I want done."

One of the democrat talking points is attempting to say that terri's brain is in a liquid state, a fluid as a result of the injuries. Proper testing SHOULD have revealed something to that effect but we only hae out of date information with out of date technology. I think this point needs to be clarified via examination if this Federal Judge (sadly a clinton appointee) is going to take this case seriously on its merrits.

[Shermy]

"Now we only have a heresay exception statement which was admitted and considered."

You're telling me this whole debate and government intrusion is about whether we believe the hubby or not? That's why it's in Federal Court?