California Laws - Probate Code
Chapter 2. Advance Health Care Directive Forms (4700-4701)

California Laws - Probate Code
DIVISION 4.7. HEALTH CARE DECISIONS
PART 2. UNIFORM HEALTH CARE DECISIONS ACT

CHAPTER 2. ADVANCE HEALTH CARE DIRECTIVE FORMS (4700-4701) ⁽⁴⁵⁶³⁾(1-click HTML)

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. ⁽⁴⁵⁶⁴⁾

4701. The statutory advance health care directive form is as follows: ⁽⁴⁵⁶⁵⁾

ADVANCE HEALTH CARE DIRECTIVE ⁽⁴⁵⁶⁶⁾

(California Probate Code Section 4701) ⁽⁴⁵⁶⁷⁾

Explanation ⁽⁴⁵⁶⁸⁾

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. ⁽⁴⁵⁶⁹⁾

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.) ⁽⁴⁵⁷⁰⁾

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: ⁽⁴⁵⁷¹⁾

(a) Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition. ⁽⁴⁵⁷²⁾

(b) Select or discharge health care providers and institutions. ⁽⁴⁵⁷³⁾

(c) Approve or disapprove diagnostic tests, surgical procedures, and programs of medication. ⁽⁴⁵⁷⁴⁾

(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation. ⁽⁴⁵⁷⁵⁾

(e) Make anatomical gifts, authorize an autopsy, and direct disposition of remains. ⁽⁴⁵⁷⁶⁾

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. ⁽⁴⁵⁷⁷⁾

Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death. ⁽⁴⁵⁷⁸⁾

Part 4 of this form lets you designate a physician to have primary responsibility for your health care. ⁽⁴⁵⁷⁹⁾

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. ⁽⁴⁵⁸⁰⁾

You have the right to revoke this advance health care directive or replace this form at any time. ⁽⁴⁵⁸¹⁾

* * * * * * * * * * * * * * * ⁽⁴⁵⁸²⁾

PART ⁽⁴⁵⁸³⁾

⁽⁴⁵⁸⁴⁾

POWER OF ATTORNEY FOR HEALTH CARE ⁽⁴⁵⁸⁵⁾

(1.1) DESIGNATION OF AGENT: I designate the ⁽⁴⁵⁸⁶⁾

following ⁽⁴⁵⁸⁷⁾

individual as my agent to make health care ⁽⁴⁵⁸⁸⁾

decisions for me: ⁽⁴⁵⁸⁹⁾

____________________________________________________ ⁽⁴⁵⁹⁰⁾

(name of individual you choose as agent) ⁽⁴⁵⁹¹⁾

____________________________________________________ ⁽⁴⁵⁹²⁾

(address) (city) (state) (ZIP ⁽⁴⁵⁹³⁾

Code) ⁽⁴⁵⁹⁴⁾

____________________________________________________ ⁽⁴⁵⁹⁵⁾

(home phone) (work phone) ⁽⁴⁵⁹⁶⁾

OPTIONAL: If I revoke my agent's authority or if my ⁽⁴⁵⁹⁷⁾

agent is ⁽⁴⁵⁹⁸⁾

not willing, able, or reasonably available to make ⁽⁴⁵⁹⁹⁾

a health care ⁽⁴⁶⁰⁰⁾

decision for me, I designate as my first alternate ⁽⁴⁶⁰¹⁾

agent: ⁽⁴⁶⁰²⁾

____________________________________________________ ⁽⁴⁶⁰³⁾

(name of individual you choose as first alternate ⁽⁴⁶⁰⁴⁾

agent) ⁽⁴⁶⁰⁵⁾

____________________________________________________ ⁽⁴⁶⁰⁶⁾

(address) (city) (state) (ZIP ⁽⁴⁶⁰⁷⁾

Code) ⁽⁴⁶⁰⁸⁾

____________________________________________________ ⁽⁴⁶⁰⁹⁾

(home phone) (work phone) ⁽⁴⁶¹⁰⁾

OPTIONAL: If I revoke the authority of my agent and ⁽⁴⁶¹¹⁾

first ⁽⁴⁶¹²⁾

alternate agent or if neither is willing, able, or ⁽⁴⁶¹³⁾

reasonably available ⁽⁴⁶¹⁴⁾

to make a health care decision for me, I designate ⁽⁴⁶¹⁵⁾

as my second ⁽⁴⁶¹⁶⁾

alternate agent: ⁽⁴⁶¹⁷⁾

____________________________________________________ ⁽⁴⁶¹⁸⁾

(name of individual you choose as second alternate ⁽⁴⁶¹⁹⁾

agent) ⁽⁴⁶²⁰⁾

____________________________________________________ ⁽⁴⁶²¹⁾

(address) (city) (state) (ZIP ⁽⁴⁶²²⁾

Code) ⁽⁴⁶²³⁾

____________________________________________________ ⁽⁴⁶²⁴⁾

(home phone) (work phone) ⁽⁴⁶²⁵⁾

(1.2) AGENT'S AUTHORITY: My agent is authorized to ⁽⁴⁶²⁶⁾

make ⁽⁴⁶²⁷⁾

all health care decisions for me, including ⁽⁴⁶²⁸⁾

decisions to provide, ⁽⁴⁶²⁹⁾

withhold, or withdraw artificial nutrition and ⁽⁴⁶³⁰⁾

hydration and all ⁽⁴⁶³¹⁾

other forms of health care to keep me alive, except ⁽⁴⁶³²⁾

as I state here: ⁽⁴⁶³³⁾

____________________________________________________ ⁽⁴⁶³⁴⁾

____________________________________________________ ⁽⁴⁶³⁵⁾

____________________________________________________ ⁽⁴⁶³⁶⁾

(Add additional sheets if needed.) ⁽⁴⁶³⁷⁾

(1.3) WHEN AGENT'S AUTHORITY BECOMES ⁽⁴⁶³⁸⁾

EFFECTIVE: My agent's authority becomes effective ⁽⁴⁶³⁹⁾

when my ⁽⁴⁶⁴⁰⁾

primary physician determines that I am unable to ⁽⁴⁶⁴¹⁾

make my own ⁽⁴⁶⁴²⁾

health care decisions unless I mark the following ⁽⁴⁶⁴³⁾

box. If I mark this ⁽⁴⁶⁴⁴⁾

box ( ), my agent's authority to make health care ⁽⁴⁶⁴⁵⁾

decisions for me ⁽⁴⁶⁴⁶⁾

takes effect immediately. ⁽⁴⁶⁴⁷⁾

(1.4) AGENT'S OBLIGATION: My agent shall make ⁽⁴⁶⁴⁸⁾

health ⁽⁴⁶⁴⁹⁾

care decisions for me in accordance with this power ⁽⁴⁶⁵⁰⁾

of attorney for ⁽⁴⁶⁵¹⁾

health care, any instructions I give in Part 2 of ⁽⁴⁶⁵²⁾

this form, and my ⁽⁴⁶⁵³⁾

other wishes to the extent known to my agent. To ⁽⁴⁶⁵⁴⁾

the extent my ⁽⁴⁶⁵⁵⁾

wishes are unknown, my agent shall make health care ⁽⁴⁶⁵⁶⁾

decisions for ⁽⁴⁶⁵⁷⁾

me in accordance with what my agent determines to ⁽⁴⁶⁵⁸⁾

be in my best ⁽⁴⁶⁵⁹⁾

interest. In determining my best interest, my ⁽⁴⁶⁶⁰⁾

agent shall consider ⁽⁴⁶⁶¹⁾

my personal values to the extent known to my agent. ⁽⁴⁶⁶²⁾

(1.5) AGENT'S POSTDEATH AUTHORITY: My agent is ⁽⁴⁶⁶³⁾

authorized to make anatomical gifts, authorize an ⁽⁴⁶⁶⁴⁾

autopsy, and ⁽⁴⁶⁶⁵⁾

direct disposition of my remains, except as I state ⁽⁴⁶⁶⁶⁾

here or in Part ⁽⁴⁶⁶⁷⁾

3 of this form: ⁽⁴⁶⁶⁸⁾

____________________________________________________ ⁽⁴⁶⁶⁹⁾

____________________________________________________ ⁽⁴⁶⁷⁰⁾

____________________________________________________ ⁽⁴⁶⁷¹⁾

(Add additional sheets if needed.) ⁽⁴⁶⁷²⁾

(1.6) NOMINATION OF CONSERVATOR: If a conservator ⁽⁴⁶⁷³⁾

of ⁽⁴⁶⁷⁴⁾

my person needs to be appointed for me by a court, ⁽⁴⁶⁷⁵⁾

I nominate the ⁽⁴⁶⁷⁶⁾

agent designated in this form. If that agent is ⁽⁴⁶⁷⁷⁾

not willing, able, or ⁽⁴⁶⁷⁸⁾

reasonably available to act as conservator, ⁽⁴⁶⁷⁹⁾

nominate the alternate ⁽⁴⁶⁸⁰⁾

agents whom I have named, in the order designated. ⁽⁴⁶⁸¹⁾

PART ⁽⁴⁶⁸²⁾

⁽⁴⁶⁸³⁾

INSTRUCTIONS FOR HEALTH CARE ⁽⁴⁶⁸⁴⁾

If you fill out this part of the form, you may ⁽⁴⁶⁸⁵⁾

strike any wording ⁽⁴⁶⁸⁶⁾

you do not want. ⁽⁴⁶⁸⁷⁾

(2.1) END-OF-LIFE DECISIONS: I direct that my ⁽⁴⁶⁸⁸⁾

health care ⁽⁴⁶⁸⁹⁾

providers and others involved in my care provide, ⁽⁴⁶⁹⁰⁾

withhold, or ⁽⁴⁶⁹¹⁾

withdraw treatment in accordance with the choice ⁽⁴⁶⁹²⁾

have marked ⁽⁴⁶⁹³⁾

below: ⁽⁴⁶⁹⁴⁾

( ) (a) Choice Not To Prolong ⁽⁴⁶⁹⁵⁾

Life ⁽⁴⁶⁹⁶⁾

I do not want my life to be prolonged if (1) I have ⁽⁴⁶⁹⁷⁾

an incurable ⁽⁴⁶⁹⁸⁾

and irreversible condition that will result in my ⁽⁴⁶⁹⁹⁾

death within ⁽⁴⁷⁰⁰⁾

relatively short time, (2) I become unconscious ⁽⁴⁷⁰¹⁾

and, to ⁽⁴⁷⁰²⁾

reasonable degree of medical certainty, I will not ⁽⁴⁷⁰³⁾

regain ⁽⁴⁷⁰⁴⁾

consciousness, or (3) the likely risks and burdens ⁽⁴⁷⁰⁵⁾

of treatment ⁽⁴⁷⁰⁶⁾

would outweigh the expected benefits, OR ⁽⁴⁷⁰⁷⁾

( ) (b) Choice To Prolong Life ⁽⁴⁷⁰⁸⁾

I want my life to be prolonged as long as possible ⁽⁴⁷⁰⁹⁾

within the limits ⁽⁴⁷¹⁰⁾

of generally accepted health care standards. ⁽⁴⁷¹¹⁾

(2.2) RELIEF FROM PAIN: Except as I state in the ⁽⁴⁷¹²⁾

following ⁽⁴⁷¹³⁾

space, I direct that treatment for alleviation of ⁽⁴⁷¹⁴⁾

pain or discomfort ⁽⁴⁷¹⁵⁾

be provided at all times, even if it hastens my ⁽⁴⁷¹⁶⁾

death: ⁽⁴⁷¹⁷⁾

____________________________________________________ ⁽⁴⁷¹⁸⁾

____________________________________________________ ⁽⁴⁷¹⁹⁾

(Add additional sheets if needed.) ⁽⁴⁷²⁰⁾

(2.3) OTHER WISHES: (If you do not agree with any ⁽⁴⁷²¹⁾

of the ⁽⁴⁷²²⁾

optional choices above and wish to write your own, ⁽⁴⁷²³⁾

or if you wish ⁽⁴⁷²⁴⁾

to add to the instructions you have given above, ⁽⁴⁷²⁵⁾

you may do so ⁽⁴⁷²⁶⁾

here.) I direct that: ⁽⁴⁷²⁷⁾

____________________________________________________ ⁽⁴⁷²⁸⁾

____________________________________________________ ⁽⁴⁷²⁹⁾

(Add additional sheets if needed.) ⁽⁴⁷³⁰⁾

PART ⁽⁴⁷³¹⁾

⁽⁴⁷³²⁾

DONATION OF ORGANS AT ⁽⁴⁷³³⁾

DEATH ⁽⁴⁷³⁴⁾

(OPTIONAL) ⁽⁴⁷³⁵⁾

(3.1) Upon my death (mark applicable box): ⁽⁴⁷³⁶⁾

( ) (a) I give any needed organs, tissues, or ⁽⁴⁷³⁷⁾

parts, OR ⁽⁴⁷³⁸⁾

( ) (b) I give the following organs, tissues, or ⁽⁴⁷³⁹⁾

parts only. ⁽⁴⁷⁴⁰⁾

____________________________________________________ ⁽⁴⁷⁴¹⁾

(c) My gift is for the following purposes (strike ⁽⁴⁷⁴²⁾

any of the following you do not want): ⁽⁴⁷⁴³⁾

(1) Transplant ⁽⁴⁷⁴⁴⁾

(2) Therapy ⁽⁴⁷⁴⁵⁾

(3) Research ⁽⁴⁷⁴⁶⁾

(4) Education ⁽⁴⁷⁴⁷⁾

PART ⁽⁴⁷⁴⁸⁾

⁽⁴⁷⁴⁹⁾

PRIMARY ⁽⁴⁷⁵⁰⁾

PHYSICIAN ⁽⁴⁷⁵¹⁾

(OPTIONAL) ⁽⁴⁷⁵²⁾

(4.1) I designate the following physician as my ⁽⁴⁷⁵³⁾

primary physician: ⁽⁴⁷⁵⁴⁾

____________________________________________________ ⁽⁴⁷⁵⁵⁾

(name of physician) ⁽⁴⁷⁵⁶⁾

____________________________________________________ ⁽⁴⁷⁵⁷⁾

(address) (city) (state) (ZIP ⁽⁴⁷⁵⁸⁾

Code) ⁽⁴⁷⁵⁹⁾

____________________________________________________ ⁽⁴⁷⁶⁰⁾

(phone) ⁽⁴⁷⁶¹⁾

OPTIONAL: If the physician I have designated above ⁽⁴⁷⁶²⁾

is not ⁽⁴⁷⁶³⁾

willing, able, or reasonably available to act as my ⁽⁴⁷⁶⁴⁾

primary physician, I designate the following ⁽⁴⁷⁶⁵⁾

physician as my primary physician: ⁽⁴⁷⁶⁶⁾

____________________________________________________ ⁽⁴⁷⁶⁷⁾

(name of physician) ⁽⁴⁷⁶⁸⁾

____________________________________________________ ⁽⁴⁷⁶⁹⁾

(address) (city) (state) (ZIP ⁽⁴⁷⁷⁰⁾

Code) ⁽⁴⁷⁷¹⁾

____________________________________________________ ⁽⁴⁷⁷²⁾

(phone) ⁽⁴⁷⁷³⁾

* * * * * * * * * * * * * * * ⁽⁴⁷⁷⁴⁾

PART ⁽⁴⁷⁷⁵⁾

(5.1) EFFECT OF COPY: A copy of this form has the ⁽⁴⁷⁷⁶⁾

same effect as the original. ⁽⁴⁷⁷⁷⁾

(5.2) SIGNATURE: Sign and date the form here: ⁽⁴⁷⁷⁸⁾

___________________________ ________________________ ⁽⁴⁷⁷⁹⁾

(date) (sign your name) ⁽⁴⁷⁸⁰⁾

___________________________ ________________________ ⁽⁴⁷⁸¹⁾

(address) (print your name) ⁽⁴⁷⁸²⁾

________________________________ ⁽⁴⁷⁸³⁾

(city) (state) ⁽⁴⁷⁸⁴⁾

(5.3) STATEMENT OF WITNESSES: I declare under ⁽⁴⁷⁸⁵⁾

penalty ⁽⁴⁷⁸⁶⁾

of perjury under the laws of California (1) that ⁽⁴⁷⁸⁷⁾

the individual who ⁽⁴⁷⁸⁸⁾

signed or acknowledged this advance health care ⁽⁴⁷⁸⁹⁾

directive is personally known to me, or that the ⁽⁴⁷⁹⁰⁾

individual's identity was proven ⁽⁴⁷⁹¹⁾

to me by convincing evidence, (2) that the ⁽⁴⁷⁹²⁾

individual signed or acknowledged this advance ⁽⁴⁷⁹³⁾

directive in my presence, (3) that the individual ⁽⁴⁷⁹⁴⁾

appears to be of sound mind and under no duress, ⁽⁴⁷⁹⁵⁾

fraud, ⁽⁴⁷⁹⁶⁾

or undue influence, (4) that I am not a person ⁽⁴⁷⁹⁷⁾

appointed as agent ⁽⁴⁷⁹⁸⁾

by this advance directive, and (5) that I am not ⁽⁴⁷⁹⁹⁾

the individual's ⁽⁴⁸⁰⁰⁾

health care provider, an employee of the ⁽⁴⁸⁰¹⁾

individual's health care ⁽⁴⁸⁰²⁾

provider, the operator of a community care ⁽⁴⁸⁰³⁾

facility, an employee ⁽⁴⁸⁰⁴⁾

of an operator of a community care facility, the ⁽⁴⁸⁰⁵⁾

operator of a residential care facility for the ⁽⁴⁸⁰⁶⁾

elderly, nor an employee of an operator ⁽⁴⁸⁰⁷⁾

of a residential care facility for the elderly. ⁽⁴⁸⁰⁸⁾

First witness Second witness ⁽⁴⁸⁰⁹⁾

___________________________ ________________________ ⁽⁴⁸¹⁰⁾

(print name) (print name) ⁽⁴⁸¹¹⁾

___________________________ ________________________ ⁽⁴⁸¹²⁾

(address) (address) ⁽⁴⁸¹³⁾

___________________________ ________________________ ⁽⁴⁸¹⁴⁾

(city) (state) (city) (state) ⁽⁴⁸¹⁵⁾

___________________________ ________________________ ⁽⁴⁸¹⁶⁾

(signature of (signature of ⁽⁴⁸¹⁷⁾

witness) witness) ⁽⁴⁸¹⁸⁾

___________________________ ________________________ ⁽⁴⁸¹⁹⁾

(date) (date) ⁽⁴⁸²⁰⁾

(5.4) ADDITIONAL STATEMENT OF WITNESSES: At least ⁽⁴⁸²¹⁾

one of the above witnesses must also sign the ⁽⁴⁸²²⁾

following ⁽⁴⁸²³⁾

declaration: ⁽⁴⁸²⁴⁾

I further declare under penalty of perjury under ⁽⁴⁸²⁵⁾

the laws of ⁽⁴⁸²⁶⁾

California that I am not related to the individual ⁽⁴⁸²⁷⁾

executing this advance health care directive by ⁽⁴⁸²⁸⁾

blood, marriage, or adoption, and ⁽⁴⁸²⁹⁾

to the best of my knowledge, I am not entitled to ⁽⁴⁸³⁰⁾

any part of the ⁽⁴⁸³¹⁾

individual's estate upon his or her death under ⁽⁴⁸³²⁾

will now existing ⁽⁴⁸³³⁾

or by operation of law. ⁽⁴⁸³⁴⁾

___________________________ ________________________ ⁽⁴⁸³⁵⁾

(signature of (signature of ⁽⁴⁸³⁶⁾

witness) witness) ⁽⁴⁸³⁷⁾

PART ⁽⁴⁸³⁸⁾

⁽⁴⁸³⁹⁾

SPECIAL WITNESS REQUIREMENT ⁽⁴⁸⁴⁰⁾

(6.1) The following statement is required only if ⁽⁴⁸⁴¹⁾

you are ⁽⁴⁸⁴²⁾

patient in a skilled nursing facility--a health ⁽⁴⁸⁴³⁾

care facility that ⁽⁴⁸⁴⁴⁾

provides the following basic services: skilled ⁽⁴⁸⁴⁵⁾

nursing care and ⁽⁴⁸⁴⁶⁾

supportive care to patients whose primary need is ⁽⁴⁸⁴⁷⁾

for availability ⁽⁴⁸⁴⁸⁾

of skilled nursing care on an extended basis. The ⁽⁴⁸⁴⁹⁾

patient advocate ⁽⁴⁸⁵⁰⁾

or ombudsman must sign the following statement: ⁽⁴⁸⁵¹⁾

STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN ⁽⁴⁸⁵²⁾

I declare under penalty of perjury under the laws ⁽⁴⁸⁵³⁾

of California ⁽⁴⁸⁵⁴⁾

that I am a patient advocate or ombudsman as ⁽⁴⁸⁵⁵⁾

designated by the ⁽⁴⁸⁵⁶⁾

State Department of Aging and that I am serving as ⁽⁴⁸⁵⁷⁾

a witness as ⁽⁴⁸⁵⁸⁾

required by Section 4675 of the Probate Code. ⁽⁴⁸⁵⁹⁾

___________________________ ________________________ ⁽⁴⁸⁶⁰⁾

(date) (sign your name) ⁽⁴⁸⁶¹⁾

___________________________ ________________________ ⁽⁴⁸⁶²⁾

(address) (print your name) ⁽⁴⁸⁶³⁾

________________________________ ⁽⁴⁸⁶⁴⁾

(city) (state) ⁽⁴⁸⁶⁵⁾