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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 caredecisions 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.
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