Living Will / Advance Health Care Directive

CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE

Living Will and Durable Power of Attorney for Health Care

(Cal. Prob. Code §§ 4700–4701)

IMPORTANT NOTICE TO PERSON EXECUTING THIS DOCUMENT

This is an important legal document. Before executing this document, you should know these important facts:

This document gives the person you designate as your agent (attorney-in-fact) the authority to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known.

Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive.

Notwithstanding this document, you have every legal right to make your own health care decisions as long as you are able to give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection at the time, and health care necessary to keep you alive may not be stopped or withheld if you object at the time.

This document gives your agent authority to consent, refuse, or withdraw consent for any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. However, your agent may NOT consent to any of the following: (a) commitment to or placement in a mental health treatment facility; (b) convulsive treatment; (c) psychosurgery; or (d) sterilization or abortion, except as otherwise provided by law. (Cal. Prob. Code § 4652.)

You have the right to revoke this document at any time and in any manner. You may revoke the designation of an agent by notifying the agent or your treating health care provider orally or in writing.

Unless you specify a shorter period, this power of attorney will exist indefinitely from the date you execute this document. If you are unable to make health care decisions for yourself at the time this power of attorney would otherwise expire, the authority of your agent will continue until you are able to make health care decisions for yourself.

TABLE OF CONTENTS

Part 1 — Power of Attorney for Health Care

1. Designation of Health Care Agent
2. Successor Agents
3. Agent Eligibility and Disqualifications
4. Agent Decision-Making Standard
5. Scope of Agent's Authority
6. Mental Health Treatment Provisions

Part 2 — Individual Health Care Instructions (Living Will)

7. General Treatment Philosophy
8. End-of-Life Treatment Instructions
9. Specific Medical Interventions
10. Pain Management and Comfort Care
11. Pregnancy Provision
12. Additional Instructions

Part 3 — Donation of Organs at Death

13. Anatomical Gift Decisions

Part 4 — Primary Physician Designation

14. Primary Physician
15. Alternate Physician

Supplemental Provisions

16. HIPAA Authorization for Release of Protected Health Information
17. POLST Coordination
18. Agent Removal and Court Proceedings
19. Revocation and Amendment
20. General Provisions

Part 5 — Execution

21. Principal's Signature
22. Option A — Notary Acknowledgment
23. Option B — Witness Attestation
24. Skilled Nursing Facility — Ombudsman/Patient Advocate Attestation
25. Agent Acceptance of Appointment

PART 1 — POWER OF ATTORNEY FOR HEALTH CARE

(Cal. Prob. Code §§ 4670–4701)

SECTION 1. DESIGNATION OF HEALTH CARE AGENT

1.1 Appointment. I, [________________________________] ("Principal"), a legal resident of the State of California, residing at [________________________________], County of [________________________________], hereby designate the following individual as my agent (attorney-in-fact) for health care decisions:

Primary Agent:

1.2 Activation. My agent's authority under this Directive becomes effective:

☐ Immediately upon execution — my agent may act at any time, whether or not I have capacity

☐ Upon incapacity only — my agent may act only when I lack capacity to make my own health care decisions, as determined under Section 1.3

1.3 Determination of Incapacity. For purposes of this Directive, I shall be deemed to lack capacity when:

☐ My attending physician determines in writing that I am unable to understand the nature and consequences of a health care decision and am unable to make and communicate an informed health care decision (Cal. Prob. Code § 4609)

☐ Two licensed physicians, one of whom is my attending physician, determine in writing that I lack capacity as defined above

☐ Other: [________________________________]

SECTION 2. SUCCESSOR AGENTS

2.1 First Successor Agent. If my Primary Agent is unable, unwilling, unavailable, or legally disqualified to serve, I designate the following individual as my First Successor Agent:

2.2 Second Successor Agent. If neither my Primary Agent nor my First Successor Agent is able to serve, I designate the following individual as my Second Successor Agent:

2.3 Order of Succession. Successor Agents shall serve in the order listed. A Successor Agent shall have the same powers and duties as the Primary Agent. A Successor Agent's authority becomes effective when the preceding agent becomes unable, unwilling, or unavailable to serve.

SECTION 3. AGENT ELIGIBILITY AND DISQUALIFICATIONS

3.1 Statutory Disqualifications. Under California law, the following individuals may NOT serve as my agent for health care unless they are related to me by blood, marriage, or adoption, or are registered domestic partners:

(a) My supervising health care provider;

(b) An operator of a community care facility;

(c) An operator of a residential care facility for the elderly; and

(d) An employee of any of the foregoing who is acting within the scope of employment.

(Cal. Prob. Code § 4659.)

3.2 Confirmation. I confirm that each agent designated in this Directive is eligible to serve and is not disqualified under Section 3.1 or any other provision of California law.

SECTION 4. AGENT DECISION-MAKING STANDARD

4.1 Primary Standard — Known Wishes. My agent shall make health care decisions in accordance with my individual health care instructions as stated in Part 2 of this Directive and any other wishes I have made known to my agent. (Cal. Prob. Code § 4684(a).)

4.2 Secondary Standard — Best Interest. If my wishes are unknown or unclear regarding a particular health care decision, my agent shall make the decision in accordance with my best interest, taking into consideration my personal values to the extent known to my agent. (Cal. Prob. Code § 4684(b).)

4.3 Consultation. My agent is encouraged, but not required, to consult with my family members, close friends, spiritual advisors, and health care providers before making significant health care decisions.

4.4 No Liability for Good-Faith Decisions. My agent shall not be subject to civil or criminal liability or professional discipline for health care decisions made in good faith under this Directive. (Cal. Prob. Code § 4684(c).)

SECTION 5. SCOPE OF AGENT'S AUTHORITY

5.1 General Authority. Subject to any limitations stated in this Directive, my agent is authorized to make all health care decisions for me, including but not limited to:

(a) Consent to, refuse, or withdraw consent for any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition;

(b) Select and discharge health care providers, including physicians, specialists, nurses, therapists, and home health aides;

(c) Approve or refuse diagnostic tests, surgical procedures, and therapeutic interventions;

(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration;

(e) Provide informed consent on my behalf;

(f) Access, review, copy, and authorize disclosure of my medical records and protected health information (subject to the HIPAA Authorization in Section 16);

(g) Apply for Medicare, Medicaid (Medi-Cal), or other public or private health care benefit programs on my behalf;

(h) Hire and compensate caregivers, home health aides, and private-duty nurses;

(i) Make decisions regarding my admission to or discharge from any hospital, hospice, skilled nursing facility, assisted living facility, or other health care institution;

(j) Authorize the use of experimental treatments or clinical trials if, in my agent's judgment, such treatment offers a meaningful possibility of benefit;

(k) Execute waivers, releases, and consents to medical treatment;

(l) Take any lawful action necessary to carry out my wishes or protect my health; and

(m) Make decisions regarding disposition of my remains, funeral arrangements, and memorial services after my death, unless I have made other arrangements.

5.2 Limitations on Agent Authority. My agent shall NOT have authority to:

(a) Consent to my commitment to or placement in a mental health treatment facility (Cal. Prob. Code § 4652);

(b) Consent to convulsive treatment (electroconvulsive therapy) (Cal. Prob. Code § 4652);

(c) Consent to psychosurgery (Cal. Prob. Code § 4652);

(d) Consent to sterilization (Cal. Prob. Code § 4652); or

(e) Consent to abortion (Cal. Prob. Code § 4652).

5.3 Additional Limitations (if any). I impose the following additional limitations on my agent's authority:

☐ No additional limitations

☐ Additional limitations: [________________________________]

SECTION 6. MENTAL HEALTH TREATMENT PROVISIONS

6.1 Mental Health Treatment Authority. Subject to the mandatory limitations in Section 5.2(a)–(c), I authorize my agent to make the following mental health treatment decisions on my behalf:

☐ Consent to voluntary admission to an inpatient psychiatric unit (note: agent CANNOT consent to involuntary commitment)

☐ Consent to the administration of psychiatric medications, including antipsychotic, antidepressant, anxiolytic, and mood-stabilizing medications

☐ Consent to outpatient mental health treatment programs

☐ Consent to behavioral health therapies, including cognitive-behavioral therapy, dialectical behavior therapy, and similar treatments

☐ Other mental health treatment authority: [________________________________]

6.2 Mental Health Treatment Limitations. I direct that my agent shall NOT consent to the following (in addition to the statutory prohibitions):

☐ No additional mental health limitations beyond the statutory prohibitions

☐ The following additional limitations: [________________________________]

PART 2 — INDIVIDUAL HEALTH CARE INSTRUCTIONS (LIVING WILL)

(Cal. Prob. Code §§ 4670, 4700–4701)

SECTION 7. GENERAL TREATMENT PHILOSOPHY

7.1 I want my agent and my health care providers to understand my general approach to medical treatment. Please select the statement that best reflects your philosophy:

☐ Quality of life is paramount. I value the quality of my life over its length. If I am unlikely to regain a meaningful quality of life, I prefer comfort-focused care and do not want aggressive interventions that merely prolong the dying process.

☐ Preserve life when possible. I want all available medical treatment to be provided to preserve my life for as long as possible, even if my condition is terminal or I am in a persistent vegetative state, unless I give specific contrary instructions below.

☐ Balanced approach. I want reasonable medical treatment that offers a realistic chance of recovery or meaningful improvement. If treatment offers no realistic benefit, I prefer comfort care.

☐ My agent decides. I trust my agent's judgment and do not wish to give specific instructions. My agent should consider my values and known wishes and make decisions in my best interest.

SECTION 8. END-OF-LIFE TREATMENT INSTRUCTIONS

8.1 Terminal Condition. If I have an incurable and irreversible condition that has been diagnosed by two physicians, and that will result in death within a relatively short time without the administration of life-sustaining treatment, and where the application of life-sustaining treatment would serve only to prolong the process of my dying, I direct the following:

☐ Withhold or withdraw all life-sustaining treatment and allow natural death

☐ Provide life-sustaining treatment

☐ Trial period — Provide life-sustaining treatment for a period of [____] days, then reassess and follow my agent's decision

☐ My agent decides — I defer to my agent's judgment

8.2 Permanent Unconscious Condition. If I am diagnosed by two physicians as being in a persistent vegetative state or permanently unconscious condition with no reasonable medical probability of regaining consciousness:

☐ Withhold or withdraw all life-sustaining treatment and allow natural death

☐ Provide life-sustaining treatment

☐ Trial period — Provide life-sustaining treatment for a period of [____] days, then reassess and follow my agent's decision

☐ My agent decides — I defer to my agent's judgment

8.3 Advanced Progressive Illness. If I have a progressive, degenerative condition (such as advanced Alzheimer's disease, end-stage ALS, advanced Parkinson's disease, or similar condition) from which I am unlikely to recover, and I am no longer able to recognize or communicate with my family:

☐ Withhold or withdraw all life-sustaining treatment and allow natural death

☐ Provide life-sustaining treatment

☐ Trial period — Provide life-sustaining treatment for a period of [____] days, then reassess and follow my agent's decision

☐ My agent decides — I defer to my agent's judgment

8.4 Irreversible Brain Damage. If I suffer irreversible brain damage or brain disease (including severe traumatic brain injury, massive stroke, or anoxic brain injury) and, in the reasonable judgment of two physicians, I will never regain the ability to make decisions and express my wishes:

☐ Withhold or withdraw all life-sustaining treatment and allow natural death

☐ Provide life-sustaining treatment

☐ Trial period — Provide life-sustaining treatment for a period of [____] days, then reassess and follow my agent's decision

☐ My agent decides — I defer to my agent's judgment

SECTION 9. SPECIFIC MEDICAL INTERVENTIONS

9.1 Cardiopulmonary Resuscitation (CPR). If my heart stops beating or I stop breathing:

☐ Do NOT attempt CPR (Do Not Resuscitate / DNR)

☐ Attempt CPR

☐ My agent decides

9.2 Mechanical Ventilation / Respirator. If I cannot breathe on my own:

☐ Do NOT use mechanical ventilation or a respirator

☐ Use mechanical ventilation for a trial period of [____] days, then reassess

☐ Use mechanical ventilation indefinitely

☐ My agent decides

9.3 Artificial Nutrition (Tube Feeding). If I cannot eat or drink by mouth:

☐ Do NOT provide artificial nutrition or tube feeding

☐ Provide artificial nutrition for a trial period of [____] days, then reassess

☐ Provide artificial nutrition indefinitely

☐ My agent decides

9.4 Artificial Hydration (IV Fluids). If I cannot drink fluids on my own:

☐ Do NOT provide artificial hydration (IV fluids)

☐ Provide artificial hydration for a trial period of [____] days, then reassess

☐ Provide artificial hydration indefinitely

☐ My agent decides

9.5 Dialysis. If my kidneys fail:

☐ Do NOT provide dialysis

☐ Provide dialysis for a trial period of [____] days, then reassess

☐ Provide dialysis indefinitely

☐ My agent decides

9.6 Antibiotics and Anti-Infective Medications. If I develop a serious infection:

☐ Do NOT provide antibiotics or anti-infective medications (except as needed for comfort)

☐ Provide antibiotics on a trial basis

☐ Provide all available antibiotic treatment

☐ My agent decides

9.7 Blood Transfusions. If I need a blood transfusion:

☐ Do NOT provide blood transfusions

☐ Provide blood transfusions

☐ My agent decides

9.8 Invasive Diagnostic Tests. If diagnostic tests requiring surgery or other invasive procedures are recommended:

☐ Do NOT perform invasive diagnostic tests

☐ Perform invasive diagnostic tests only if they may lead to treatment that could improve my condition

☐ My agent decides

9.9 Surgery. If surgery is recommended:

☐ Do NOT perform surgery (except for comfort or pain relief)

☐ Perform surgery only if it offers a reasonable chance of meaningful recovery

☐ Perform all recommended surgery

☐ My agent decides

SECTION 10. PAIN MANAGEMENT AND COMFORT CARE

10.1 Pain Relief. Regardless of any other instructions in this Directive, I direct that I receive adequate pain relief and comfort care at all times. I understand and accept that pain medication may have side effects, including but not limited to sedation, respiratory depression, or the possibility of hastening death, and I consent to such treatment.

10.2 Palliative Care. I direct that palliative care be provided to keep me comfortable and to manage pain, shortness of breath, anxiety, nausea, and other symptoms, even if such care may shorten my life.

10.3 Hospice Care. If my condition is terminal and curative treatment is no longer effective:

☐ I wish to receive hospice care (in-home or in a hospice facility) focused on comfort and dignity

☐ I wish to continue receiving curative treatment as long as possible

☐ My agent decides when to transition to hospice care

10.4 Environment Preferences. If I am terminally ill or permanently unconscious:

☐ I prefer to die at home, if possible

☐ I prefer to die in a hospital or medical facility

☐ I prefer to die in a hospice facility

☐ My agent decides the most appropriate setting

SECTION 11. PREGNANCY PROVISION

☐ This section does not apply to me.

☐ If I am pregnant, I direct the following:

☐ My advance directive shall remain in full force and effect regardless of my pregnancy.

☐ Life-sustaining treatment shall be provided during my pregnancy to the extent necessary to maintain the pregnancy to the point of live delivery, regardless of my other instructions in this Directive.

☐ My agent shall make decisions regarding life-sustaining treatment during my pregnancy, considering the viability of the fetus, my prognosis, and my previously expressed wishes.

☐ Other instructions: [________________________________]

SECTION 12. ADDITIONAL INSTRUCTIONS

12.1 Religious or Spiritual Preferences. I wish the following religious, spiritual, or cultural practices to be observed in connection with my health care and end-of-life treatment:

☐ No specific preferences

☐ Preferences: [________________________________]

12.2 Visitors and Access. I direct the following regarding visitors and access during my incapacity:

☐ My agent shall have sole discretion regarding visitors and access

☐ The following persons should always be permitted to visit: [________________________________]

☐ The following persons should NOT be permitted to visit: [________________________________]

12.3 Other Instructions. [________________________________]

PART 3 — DONATION OF ORGANS AT DEATH

(Cal. Health & Safety Code § 7150 et seq. — Uniform Anatomical Gift Act)

SECTION 13. ANATOMICAL GIFT DECISIONS

13.1 Organ and Tissue Donation. Upon my death, I make the following anatomical gift (select one):

☐ I donate ALL of my organs, tissues, and parts for any purpose authorized by law, including transplantation, therapy, medical research, and education

☐ I donate ONLY the following organs, tissues, or parts:

☐ Heart
☐ Lungs
☐ Liver
☐ Kidneys
☐ Pancreas
☐ Intestines
☐ Corneas / Eyes
☐ Skin
☐ Bone and connective tissue
☐ Heart valves
☐ Blood vessels
☐ Other: [________________________________]

☐ I donate my organs and tissues ONLY for the following purposes:

☐ Transplantation
☐ Therapy
☐ Medical research
☐ Medical education
☐ Advancement of medical science

☐ I donate my entire body to: [________________________________] for purposes of medical education and research

☐ I do NOT wish to make any anatomical gift

13.2 Donation Coordination. If I have chosen to donate organs or tissues, I direct the following:

(a) Life-sustaining treatment may be continued after determination of death solely for the purpose of maintaining organ viability for transplantation, to the extent permitted by law;

(b) My agent and health care providers shall cooperate with the organ procurement organization to facilitate the donation process; and

(c) This gift supersedes any contrary indication by my family members after my death, unless I revoke this gift before my death.

13.3 Existing Donor Registration. I have registered as an organ donor with:

☐ California Department of Motor Vehicles (donor designation on driver's license or ID)

☐ Donate Life California Registry

☐ Other: [________________________________]

☐ I have NOT registered as an organ donor

PART 4 — PRIMARY PHYSICIAN DESIGNATION

SECTION 14. PRIMARY PHYSICIAN

14.1 I designate the following physician to have primary responsibility for my health care:

SECTION 15. ALTERNATE PHYSICIAN

15.1 If the physician named above is not available, I designate the following alternate physician:

15.2 No Designation. If I have not designated a primary physician, or if my designated physician is unavailable, the physician with primary responsibility for my health care shall serve as my primary physician for purposes of this Directive.

SUPPLEMENTAL PROVISIONS

SECTION 16. HIPAA AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION

(45 C.F.R. § 164.508)

16.1 Authorization. I hereby authorize any health care provider, health plan, health care clearinghouse, physician, hospital, clinic, laboratory, pharmacy, or other covered entity that has provided treatment or services to me, or that has paid for or is seeking payment for such services, to release and disclose my protected health information ("PHI") to my agent designated in Part 1 of this Directive (including any successor agent then serving).

16.2 Scope of Information Authorized for Release. This authorization covers the release and disclosure of:

(a) All medical records, including records relating to treatment for mental health conditions, substance abuse, HIV/AIDS, sexually transmitted infections, and genetic testing results;

(b) Billing records, health insurance records, and claims information;

(c) Prescription drug records and pharmacy records;

(d) Laboratory test results and diagnostic imaging;

(e) Records of any prior health care directives, POLST forms, or DNR orders; and

(f) Any other information necessary for my agent to make informed health care decisions.

16.3 Persons/Entities Authorized to Receive PHI. The following persons are authorized to receive, review, and obtain copies of my PHI:

(a) My agent or successor agent designated under Part 1 of this Directive;

(b) My primary physician designated under Part 4;

(c) My attorney: [________________________________];

(d) Other: [________________________________]

16.4 Purpose. The purpose of this authorization is to allow my agent to make informed health care decisions on my behalf, and to facilitate care coordination among my health care providers.

16.5 Expiration. This authorization does not expire and shall remain in effect until I revoke it in writing or until this Directive is revoked.

16.6 Right to Revoke. I may revoke this authorization at any time by written notice to any covered entity to which it has been presented. Revocation shall not be effective as to disclosures already made in reliance on this authorization.

16.7 Acknowledgment. I acknowledge that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by HIPAA.

SECTION 17. POLST COORDINATION

(Cal. Prob. Code §§ 4780-4786; Cal. Health & Safety Code § 1862 et seq.)

17.1 Existing POLST. I have a POLST form:

☐ Yes — Date of most recent POLST: [__/__/____]

☐ No — I do not currently have a POLST form

17.2 Consistency. If I have both this Directive and a POLST form, and there is a conflict between them regarding specific treatment decisions, the following shall control:

☐ The POLST form shall take precedence over this Directive, as it represents more recent and specific medical orders developed in consultation with my physician

☐ This Directive shall take precedence over the POLST form

☐ My agent decides which document more accurately reflects my current wishes

17.3 Future POLST. I authorize my agent to complete, update, modify, or revoke a POLST form on my behalf when I lack capacity, consistent with my wishes expressed in this Directive. My agent should consult with my physician before completing or modifying a POLST.

SECTION 18. AGENT REMOVAL AND COURT PROCEEDINGS

(Cal. Prob. Code § 4766)

18.1 Right to Petition. Any of the following persons may petition the Superior Court of the State of California to:

(a) Determine whether the Principal lacks or has recovered capacity;

(b) Determine whether the advance directive is in effect or has been revoked;

(c) Determine whether the acts or proposed acts of the agent are consistent with the Principal's wishes or, if unknown, the Principal's best interest;

(d) Compel the agent to submit an accounting;

(e) Remove the agent and appoint a successor; or

(f) Grant any other appropriate relief.

(Cal. Prob. Code § 4766(a).)

18.2 Persons Authorized to Petition. The following persons may petition the court: the Principal (if competent), the agent, the Principal's spouse or registered domestic partner, a relative of the Principal, a person who would be the Principal's presumptive heir, the Principal's conservator or guardian, a health care provider currently providing care to the Principal, and any other interested person. (Cal. Prob. Code § 4766(b).)

SECTION 19. REVOCATION AND AMENDMENT

19.1 Revocation. I may revoke this Directive at any time and in any manner, including by:

(a) A signed, dated written instrument;

(b) Personally informing my attending physician or my agent, orally or in writing, of my intent to revoke;

(c) Executing a subsequent advance health care directive that is inconsistent with this Directive; or

(d) Any other expression of intent to revoke, provided that such expression is communicated to my agent or health care provider.

(Cal. Prob. Code § 4695.)

19.2 Partial Revocation. I may revoke any specific provision of this Directive without revoking the entire Directive.

19.3 Amendment. I may amend this Directive at any time by executing a written amendment signed and dated by me, and either notarized or witnessed in conformity with Cal. Prob. Code § 4673.

19.4 Effect of Divorce or Annulment. If my designated agent is my spouse or registered domestic partner, and our marriage or domestic partnership is later dissolved or annulled, the designation of that person as my agent is automatically revoked unless I have provided otherwise in this Directive. (Cal. Prob. Code § 4697.)

SECTION 20. GENERAL PROVISIONS

20.1 Severability. If any provision of this Directive is held invalid or unenforceable, the remaining provisions shall remain in full force and effect to the maximum extent permitted by law.

20.2 Integration. This Directive constitutes my entire advance health care directive and supersedes all prior advance health care directives, living wills, or similar documents I have previously executed. I intend for this Directive to be my sole advance health care directive.

20.3 Copies. A photocopy, facsimile, or electronically transmitted copy of this Directive shall have the same force and effect as the original. (Cal. Prob. Code § 4689.)

20.4 Reliance by Third Parties. No health care provider, health care institution, or other person who acts in good-faith reliance on this Directive shall be subject to civil or criminal liability or professional discipline for such reliance. (Cal. Prob. Code § 4740.)

20.5 Provider Compliance. A health care provider who declines to comply with my individual health care instructions or the decisions of my agent shall promptly inform me (if I have capacity) or my agent and shall make reasonable efforts to assist in the transfer of my care to another provider who is willing to comply. (Cal. Prob. Code § 4734.)

20.6 Governing Law. This Directive shall be governed by and construed in accordance with the laws of the State of California, including the Health Care Decisions Law (Cal. Prob. Code §§ 4600–4806).

20.7 No Assignment. The authority granted to my agent under this Directive is personal and may not be assigned or delegated to any other person, except to a designated successor agent under Section 2.

20.8 Gender and Number. As used in this Directive, words of one gender include all genders, and words used in the singular include the plural and vice versa.

20.9 Compensation and Reimbursement. My agent shall serve without compensation unless I specifically provide otherwise below, but shall be entitled to reimbursement for reasonable expenses incurred in carrying out duties under this Directive, payable from my assets.

☐ My agent shall serve WITHOUT compensation (other than expense reimbursement)

☐ My agent shall receive compensation of $[________________________________] per [________________________________] for service as my health care agent

20.10 Secretary of State Registry. I understand that California maintains an Advance Health Care Directive Registry through the Secretary of State's office. I may, but am not required to, register this Directive with the Registry. (Cal. Prob. Code § 4800.)

☐ I intend to register this Directive with the California Secretary of State

☐ I do not intend to register this Directive at this time

PART 5 — EXECUTION

SECTION 21. PRINCIPAL'S SIGNATURE

I, [________________________________], declare under penalty of perjury under the laws of the State of California that I am the person identified as Principal in this Directive. I am at least 18 years of age, of sound mind, and I am signing this Directive voluntarily, without fraud, duress, or undue influence. I have read this Directive (or had it read to me), I understand its contents and legal effect, and I intend this document to be my advance health care directive.

I understand that this document allows my agent to make health care decisions for me if I become unable to make those decisions myself. I understand that my agent's authority includes the power to consent to my physicians not giving me treatment or stopping treatment that is necessary to keep me alive.

Principal Signature:

Signature: __________________________________

Printed Name: [________________________________]

Date: [__/__/____]

SECTION 22. OPTION A — NOTARY ACKNOWLEDGMENT

(Cal. Civ. Code § 1189)

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California

County of [________________________________]

On [__/__/____], before me, [________________________________], a Notary Public, personally appeared [________________________________], who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature: __________________________________

(Seal)

SECTION 23. OPTION B — WITNESS ATTESTATION

(Cal. Prob. Code §§ 4673–4674)

WITNESS #1

I declare under penalty of perjury under the laws of the State of California that:

1. I am at least 18 years of age;
2. I am NOT the person appointed as agent by this document;
3. I am NOT a health care provider, nor an employee of a health care provider or health care institution currently providing treatment or care to the Principal;
4. I am NOT the operator of, nor an employee of, a community care facility or residential care facility for the elderly in which the Principal resides;
5. I personally witnessed the Principal sign (or acknowledge his/her/their signature on) this Directive; and
6. I believe the Principal is of sound mind and is signing this Directive voluntarily, without fraud, duress, or undue influence.

☐ I am NOT related to the Principal by blood, marriage, or adoption, and I am NOT entitled to any portion of the Principal's estate upon death

☐ I AM related to the Principal by blood, marriage, or adoption, OR I am entitled to a portion of the Principal's estate upon death

WITNESS #2

I declare under penalty of perjury under the laws of the State of California that:

1. I am at least 18 years of age;
2. I am NOT the person appointed as agent by this document;
3. I am NOT a health care provider, nor an employee of a health care provider or health care institution currently providing treatment or care to the Principal;
4. I am NOT the operator of, nor an employee of, a community care facility or residential care facility for the elderly in which the Principal resides;
5. I personally witnessed the Principal sign (or acknowledge his/her/their signature on) this Directive; and
6. I believe the Principal is of sound mind and is signing this Directive voluntarily, without fraud, duress, or undue influence.

☐ I am NOT related to the Principal by blood, marriage, or adoption, and I am NOT entitled to any portion of the Principal's estate upon death

☐ I AM related to the Principal by blood, marriage, or adoption, OR I am entitled to a portion of the Principal's estate upon death

SECTION 24. SKILLED NURSING FACILITY — OMBUDSMAN / PATIENT ADVOCATE ATTESTATION

(Cal. Prob. Code § 4675)

☐ The Principal IS a patient in a skilled nursing facility at the time of execution — Ombudsman/Patient Advocate attestation below is REQUIRED

☐ The Principal is NOT a patient in a skilled nursing facility at the time of execution — this Section does not apply

OMBUDSMAN / PATIENT ADVOCATE ATTESTATION

I, the undersigned, am a patient advocate or ombudsman as designated by the State Department of Aging (or the local long-term care ombudsman program). I am serving as a witness to the execution of this Advance Health Care Directive as required by California Probate Code § 4675.

I declare under penalty of perjury under the laws of the State of California that:

1. I have verified the identity of the Principal to my satisfaction;
2. I believe the Principal is of sound mind and is executing this Directive voluntarily, without fraud, duress, or undue influence;
3. I have explained the nature and effect of this Directive to the Principal; and
4. I have no personal or financial interest in the Principal's health care or estate.

SECTION 25. AGENT ACCEPTANCE OF APPOINTMENT

I, [________________________________], have been designated as the health care agent (Primary Agent / Successor Agent) for the Principal identified in this Directive. By signing below, I acknowledge that:

1. I have read this Directive and understand its contents;
2. I understand the scope of my authority and the limitations on that authority, including the prohibitions in Cal. Prob. Code § 4652;
3. I understand my obligation to act in accordance with the Principal's wishes as stated in this Directive, and if the Principal's wishes are unknown, in accordance with the Principal's best interest (Cal. Prob. Code § 4684);
4. I accept the appointment and agree to serve as the Principal's health care agent in good faith; and
5. I understand that I may decline to serve or resign at any time by notifying the Principal (if competent) or the successor agent.

Agent Signature:

Signature: __________________________________

Printed Name: [________________________________]

Date: [__/__/____]

Successor Agent Acceptance (if applicable):

Signature: __________________________________

Printed Name: [________________________________]

Date: [__/__/____]

DISTRIBUTION CHECKLIST

☐ Primary Agent

☐ Successor Agent(s)

☐ Primary Physician

☐ Alternate Physician

☐ Hospital(s) likely to provide treatment

☐ Attorney

☐ Spouse / Registered Domestic Partner

☐ Close family members

☐ Skilled nursing facility (if applicable)

☐ California Secretary of State — Advance Health Care Directive Registry (optional)

☐ Safe deposit box or fireproof home safe (retain original)

☐ Other: [________________________________]

SOURCES AND REFERENCES

California Statutes — Health Care Decisions Law

• Cal. Prob. Code §§ 4600–4806 — Health Care Decisions Law (Complete Division 4.7)
• Cal. Prob. Code § 4609 — Capacity Defined
• Cal. Prob. Code § 4621 — Nomination of Conservator
• Cal. Prob. Code § 4633 — Agent Decision-Making Standard
• Cal. Prob. Code § 4650 — Legislative Findings — Patient Autonomy
• Cal. Prob. Code § 4652 — Mental Health Treatment Limitations
• Cal. Prob. Code § 4670 — Advance Directive Requirements
• Cal. Prob. Code §§ 4673–4675 — Execution, Witness Requirements, and Skilled Nursing Facility
• Cal. Prob. Code § 4674 — Witness Disqualifications
• Cal. Prob. Code § 4675 — Skilled Nursing Facility Ombudsman Requirement
• Cal. Prob. Code § 4684 — Agent Decision-Making Standard
• Cal. Prob. Code § 4689 — Reliance on Copies
• Cal. Prob. Code § 4695 — Immunities for Health Care Providers
• Cal. Prob. Code § 4697 — Effect of Dissolution of Marriage
• Cal. Prob. Code §§ 4700–4701 — Statutory Advance Directive Form
• Cal. Prob. Code § 4734 — Provider Compliance Obligation
• Cal. Prob. Code § 4740 — Provider Immunity
• Cal. Prob. Code § 4766 — Petition for Court Review
• Cal. Prob. Code §§ 4800–4806 — Advance Health Care Directive Registry

Related California Statutes

• Cal. Prob. Code §§ 4780-4786 — Request Regarding Resuscitative Measures / POLST
• Cal. Health & Safety Code § 1862 et seq. — POLST eRegistry
• Cal. Health & Safety Code § 7150 et seq. — Uniform Anatomical Gift Act
• Cal. Civ. Code § 1189 — Notary Acknowledgment Form

Federal Statutes

• 45 C.F.R. § 164.508 — HIPAA Authorization Requirements

Resources

• California Secretary of State — Advance Health Care Directive Registry
• California POLST — Physician Orders for Life-Sustaining Treatment
• Donate Life California

Prepared for attorney review. This template is provided for informational purposes only and does not constitute legal advice.