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Table
of Contents | Table
of Legal Forms | Health Section
| Latin
Recipes Section | Probate
Code
General
Power of Attorney
Form
Note: The Power of Attorney Health
Care below relates specifically to health care decisions. It does not
cover business and personal affairs and transactions. For a general power of
attorney click:
General
Power of Attorney
Form
An advance health care directive that conflicts with an earlier advance directive revokes the earlier advance directive to the extent of the conflict. (Added by Stats.1999, c. 658 (A.8.891), § 39, operative July 1, 2000.)
Source
of Statutory Power of Attorney Health Care
Probate
Code: CHAPTER 2. ADVANCE HEALTH CARE DIRECTIVE FORMS
Sections
§
4700. Use of particular form not required; effect of form or other writing
Operative
July 1, 2000.
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. (Added by Stats.1999, c. 658 (A.B.891), § 39, operative July 1, 2000.)
For
another section of this number, see Part 4, Durable Powers of Attorney for
Health Care, ante.
§
4701. Statutory form
Operative
July 1, 2000.
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.
POWERS OF ATTORNEY
POWER OF ATTORNEY FOR HEALTH CARE
(1.1) DESIGNATION OF AGENT: I designate the
following individual as my agent to make health car, 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 1 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 1 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 1 am unable to make my own health care decisions unless 1 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 POST DEATH 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 1 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: 1 direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice 1 have marked below:
p (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
p (b) Choice To Prolong Life
1 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):
p (a) I give any needed organs, tissues, or parts, OR
p (b) I give the following organs, tissues, or parts only.
p (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 3 physician.
__________________________________________________________________________________________
(name of physician)
_________________________________________________________________________________________
(address) (city) (state) (ZIP Code)
_________________________________________________________________________________________
(phone)
OPTIONAL: If the physician 1 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 effects 5 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 1 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 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 STATEMENT
(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
1 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)
LEGAL REFERENCES
Legislative Provisions
Probate
Code
PJJJJJ
California Probate Code Table of Contents
PART 5
For Part 5 judicial proceedings concerning powers of attorney , of division 4.5, see Probate Code Section 4900 et seq.
(Added by Stats.1999, c. 658 (A.B.891), § 39, operative July 1, 2000.)
Division
4.7
HEALTH
CARE DECISIONS
Part
Section
1.
Definitions and General . . . . . . . . . . . . . . . 4600
2.
Uniform Health Care Decisions Act . . . . . 4670
3.
Judicial Proceedings 4750
4.
Request to Forgo Resuscitative Measures 4780
5.
Advance Health Care Directive Registry . 4800
Part 1
DEFINITIONS
AND GENERAL
Chapter
Section
1.
Short Title and Definitions 4600
2.
General Provisions 46.50
3.
Transitional Provisions . . . 4665
CHAPTER
1. SHORT TITLE AND DEFINITIONS
Section
4603.
Definitions governing construction of this division.
4605.
Advance health care directive.
4611.
Community care facility.
4619.
Health care institution.
4623.
Individual health care instruction.
4629.
Power of attorney for health care.
4637.
Residential care facility for the elderly.
4639.
Skilled nursing facility.
4641.
Supervising health care provider.
§
4600. Short title
Operative
July 1, 2000.
This
division may be cited as the Health Care Decisions
Law.
(Added by Stats.1999, c. 658 (A.R891), § 39, operative July], 2000.)
For
another section of this number, see Part 4, Durable Powers of Attorney for
Health Care, ante.
§
4603. Definitions governing construction of this division
Operative
July 1, 2000.
Unless
the provision or context otherwise requires, the
definitions
in this chapter govern the construction of this
For another section of this number, see Pan 4,
Durable Powers of Attorney for Health Care, ante.
§§ 4702 to 4704. Editorial Note
For sections of these numbers, see Part 4, Durable Powers of Attorney for Health Care, ante.
CHAPTER 3. HEALTH CARE SURROGATES
Section 4711. Designation of surrogate. 4714. Decisions based on patient's best interests. 4715. Disqualification of person from acting as surrogate.
§ 4711. Designation of surrogate
Operative July 1, 2000.
A patient may designate an adult as a surrogate to make health care decisions by personally informing the supervising health care provider. An oral designation of a surrogate shall be promptly recorded in the patient's health care record and is effective only during the course of treatment or illness or during the stay in the health care institution when the designation is made. (Added by Stats.1999, c. 658 (A.B.891), § 39, operative July 1, 2000.)
§ 4714. Decisions based on patient's best interests
Operative July 1, 2000.
A surrogate, including a person acting as a surrogate, shall make a health care decision in accordance with the patient's individual health care instructions, if any, and other wishes to the extent known to the surrogate. Otherwise, the surrogate shall make the decision in accordance with the surrogate's determination of the patient's best interest. In determining the patient's best interest, the surrogate shall consider the patient's personal values to the extent known to the surrogate. (Added by Stats.1999, c. 658 (A.R891), § 39, operative July 1, 2000.)
§ 4715. Disqualification of person from acting as surrogate
Operative July 1, 2000.
A patient having capacity at any time may disqualify another person, including a member of the patient's family, from acting as the patient's surrogate by a signed writing or by personally informing the supervising health care provider of the disqualification. (Added by Stats. 1999, c. 658 (A.B.891), § 39, operative July 1, 2000.)
§§ 4720 to 4727. Editorial Note
For sections of these numbers, see Part 4, Durable Powers of Attorney for Health Care, ante.
CHAPTER 4. DUTIES OF HEALTH CARE PROVIDERS
Section
4730. Communication to patient.
4731. Recording of information in patient's health care record; notification to agent or surrogate regarding revocation or disqualification.
4732. Primary physician; duty to record information regarding patient's capacity.
251