CALIFORNIA HEALTH CARE POWER OF ATTORNEY

(Advance Health Care Directive – Cal. Prob. Code § 4600 et seq.)

[// GUIDANCE: This template is drafted to comply with the California Health Care Decisions Law (Probate Code §§ 4600–4806). Customize all bracketed fields before execution. Confirm that the final document meets the Principal’s specific medical, ethical, and religious preferences.]

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Operative Provisions
4. Representations & Warranties
5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation
8. Dispute Resolution
9. General Provisions
10. Execution Block

1. DOCUMENT HEADER

1.1 Title; Parties

This California Health Care Power of Attorney (“Directive”) is executed by [PRINCIPAL NAME], residing at [PRINCIPAL ADDRESS] (“Principal”), in favor of the health-care agent appointed herein (“Agent”).

1.2 Recitals

A. Principal desires to authorize Agent to make health-care decisions on Principal’s behalf if Principal is unable to do so personally.
B. This Directive is executed pursuant to, and shall be construed in accordance with, the California Health Care Decisions Law, Cal. Prob. Code § 4600 et seq.
C. Execution of this Directive constitutes consideration sufficient to create the powers and duties herein.

1.3 Effective Date; Jurisdiction

This Directive becomes effective upon the earlier of (i) a determination of Principal’s incapacity by the attending physician, or (ii) [SPECIFY, e.g., “immediately upon execution”], and shall be governed exclusively by the substantive and procedural laws of the State of California.

2. DEFINITIONS

For purposes of this Directive, the following terms have the meanings set forth below. Defined terms appear in initial capital letters throughout this document.

“Advance Directive” or “Directive” – This California Health Care Power of Attorney, together with all schedules, exhibits, and duly-executed amendments.

“Agent” – The individual designated in Section 3.1 to act for the Principal, including any Successor Agent appointed under Section 3.2.

“Good Faith” – Honesty in fact and the observance of reasonable standards of fair dealing.

“Health Care” – Any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect Principal’s physical or mental condition.

“HIPAA” – The Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191, and its implementing regulations, 45 C.F.R. Parts 160 & 164.

“Incapacity” – A determination in writing by a licensed physician that Principal lacks the ability to understand the nature and consequences of proposed health-care decisions and to make and communicate informed decisions.

“Life-Sustaining Treatment” – Medical procedures or interventions that, in reasonable medical judgment, serve only to prolong the process of dying and where death is imminent if such procedures are withheld or withdrawn.

“Principal” – The person executing this Directive.

“Qualified Physician” – A physician licensed under the California Business & Professions Code and with responsibility for Principal’s health-care.

“Successor Agent” – An alternate Agent authorized to act if the primary Agent is unable or unwilling to serve.

3. OPERATIVE PROVISIONS

3.1 Appointment of Agent

Principal hereby appoints [AGENT NAME], residing at [AGENT ADDRESS], as Principal’s Agent to make all Health-Care decisions on Principal’s behalf, subject to the limitations in this Directive.

[// GUIDANCE: Insert at least one Successor Agent to ensure continuity.]

3.2 Appointment of Successor Agent(s)

1. First Successor Agent: [SUCCESSOR AGENT 1 NAME & ADDRESS].
2. Second Successor Agent: [SUCCESSOR AGENT 2 NAME & ADDRESS].
   Each Successor Agent shall serve only if all previously-designated Agents are unable or unwilling to act.

3.3 Scope of Authority

Subject to Section 3.4, Agent shall have full power to:
a. Consent to, refuse, or withdraw any Health Care, including surgery, medication, diagnostic tests, and Life-Sustaining Treatment.
b. Make decisions regarding organ donation, autopsy, and disposition of remains.
c. Access, request, and receive any of Principal’s protected health information (“PHI”) pursuant to the HIPAA Authorization in Section 3.8.
d. Hire and discharge medical, social service, or mental-health professionals.
e. Authorize admission to or discharge from hospitals, nursing homes, assisted-living facilities, hospice, or similar institutions.

3.4 End-of-Life Provisions

1. Life-Sustaining Treatment: If I am terminally ill or permanently unconscious, it is my desire that Life-Sustaining Treatment [SELECT ONE: be withheld / be continued / Agent decides].
2. Artificial Nutrition & Hydration: [SELECT ONE: withhold / continue / Agent decides].
3. Palliative Care: I direct that medication be provided as needed for pain relief even if it hastens my death, unless expressly refused here: [SPECIFY].

[// GUIDANCE: The selections above should be initialed by the Principal to enhance clarity.]

3.5 Do-Not-Resuscitate (DNR) Orders

Agent is authorized to execute physician orders, including a POLST or DNR, consistent with this Directive.

3.6 Nomination of Conservator

If a conservatorship is sought, Principal nominates the then-acting Agent as conservator of the person pursuant to Cal. Prob. Code § 1810.

3.7 Anatomical Gifts

[OPTIONAL] Principal wishes to make an anatomical gift as follows: [SPECIFY OR “NONE”].

3.8 HIPAA Authorization

Principal expressly authorizes any Covered Entity to disclose PHI to Agent to the same extent as Principal, effective immediately and surviving Principal’s death to the extent necessary to carry out Agent’s duties.

4. REPRESENTATIONS & WARRANTIES

4.1 Principal represents that:
a. Principal is at least eighteen (18) years old, of sound mind, and not acting under duress or undue influence.
b. All personal information provided herein is accurate.

4.2 Each Agent represents, by accepting appointment, that the Agent:
a. Is at least eighteen (18) years old and legally competent.
b. Will act in Good Faith and in accordance with Principal’s known wishes.
c. Has read and understands this Directive.

5. COVENANTS & RESTRICTIONS

5.1 Agent shall:
a. Consult with healthcare providers to ascertain medical facts.
b. Follow Principal’s expressed wishes and, if unknown, Principal’s best interests.
c. Keep reasonably detailed records of significant healthcare decisions.

5.2 Agent shall not:
a. Delegate authority granted herein (except to a duly-appointed Successor Agent).
b. Execute any action that constitutes financial exploitation or self-dealing.
c. Act contrary to any valid court order.

5.3 Notice Obligation
Agent shall notify Successor Agent(s) promptly upon inability or unwillingness to continue serving.

6. DEFAULT & REMEDIES

6.1 Events of Default
The following constitute defaults:
a. Agent’s breach of Section 5.1 or 5.2;
b. Agent’s gross negligence, willful misconduct, or conversion of Principal’s property;
c. Judicial determination of Agent’s incapacity.

6.2 Cure Period
Upon default, Agent shall have five (5) days after written notice from an interested person to cure, unless immediate removal is warranted by imminent risk to Principal.

6.3 Remedies
a. Automatic removal of Agent upon failure to cure.
b. Appointment of next Successor Agent.
c. Petition to the [COUNTY NAME] Probate Court for injunctive relief consistent with Cal. Prob. Code § 4766.
d. Recovery of reasonable attorneys’ fees and costs by the prevailing party.

7. RISK ALLOCATION

7.1 Indemnification (Good-Faith Standard)

Principal shall indemnify and hold harmless Agent from any loss, liability, or expense incurred for actions taken in Good Faith under this Directive, except to the extent arising from Agent’s gross negligence or willful misconduct.

7.2 Limitation of Liability

No Agent shall be liable for any act or omission undertaken in Good Faith and in substantial compliance with this Directive and California law.

7.3 Insurance

[OPTIONAL] Principal shall maintain long-term care or other insurance naming Agent as an authorized representative for claim purposes.

7.4 Force Majeure

Agent shall not be liable for non-performance caused by circumstances beyond Agent’s reasonable control, including acts of God, war, terrorism, pandemic, or governmental order.

8. DISPUTE RESOLUTION

8.1 Governing Law
This Directive shall be governed by the laws of the State of California without regard to conflicts-of-law principles.

8.2 Forum Selection
Any action arising under or relating to this Directive shall be brought exclusively in the probate division of the [COUNTY NAME] Superior Court.

8.3 Arbitration
Arbitration is not available under this Directive.

8.4 Jury Waiver
Jury trial waiver is not available under this Directive.

8.5 Injunctive Relief
Nothing herein limits any party’s right to seek provisional or injunctive relief to enforce Health-Care decisions consistent with this Directive.

9. GENERAL PROVISIONS

9.1 Amendment & Revocation
Principal may amend or revoke this Directive at any time by (i) a signed writing, (ii) physically canceling or destroying this document, or (iii) an oral statement to the attending physician, subsequently documented in writing. Revocation of Agent’s authority does not require revocation of end-of-life instructions unless expressly stated.

9.2 Reliance by Third Parties
Third parties may rely on a photocopy, facsimile, or electronically transmitted copy of this Directive without liability.

9.3 Assignment
This Directive is personal to the Agent and may not be assigned.

9.4 Severability
If any provision is held invalid, the remaining provisions shall remain enforceable to the fullest extent permitted by law.

9.5 Entire Agreement
This Directive constitutes the entire agreement regarding Health-Care decisions and supersedes all prior inconsistent directives.

9.6 Counterparts; Electronic Signatures
This Directive may be executed in counterparts, each of which is deemed an original, and by electronic signature in compliance with Cal. Civ. Code § 1633.7.

10. EXECUTION BLOCK

[// GUIDANCE: California requires EITHER (i) acknowledgment before a notary public OR (ii) signature of two qualified adult witnesses. If the Principal resides in a skilled nursing facility, an Ombudsman witness is also required.]

10.1 Principal’s Signature

I, [PRINCIPAL NAME], sign my name to this California Health Care Power of Attorney on [DATE] at [CITY, STATE].

[PRINCIPAL NAME], Principal

10.2 Agent’s Acceptance

I, [AGENT NAME], accept the appointment as Agent and agree to act in Good Faith under this Directive.

[AGENT NAME], Agent
Date: _______

10.3 Successor Agent(s) Acceptance

(Include additional signature lines as needed.)

10.4 OPTION A – Notary Acknowledgment

State of California ▪ County of [COUNTY]

On [DATE], before me, [NOTARY NAME], Notary Public, personally appeared [PRINCIPAL NAME], who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same in his/her authorized capacity.

Notary Public
(My Commission Expires: ______)
[NOTARY SEAL]

10.5 OPTION B – Witness Declaration

We declare that the Principal is personally known to us, appears to be of sound mind, and is acting voluntarily, free from duress or undue influence. We are not (i) appointed as Agent, (ii) the Principal’s health-care provider or employee thereof, nor (iii) entitled to any portion of the Principal’s estate upon death by will or intestacy.

Witness #1: ____ Date: _
Print Name: _____ Address: ____

Witness #2: ____ Date: _
Print Name: _____ Address: ____
[If in skilled nursing facility:]

Long-Term Care Ombudsman (required)
Date: _______

[// GUIDANCE:
1. Provide signed copies to the Agent, Successor Agent(s), primary physician, and relevant medical facilities.
2. Upload to any state-recognized electronic registry, if available.
3. Review and update every 2–3 years or upon major health changes.]