This form is legal in California. Changes should be made for each person.
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 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 the advance health care directive or replace this form at any time.
PART 1
POWER OF ATTORNEY FOR HEALTH CARE
1.1 DESIGNATION OF AGENTS: I designate the following as agents to make health care decisions for me, successively and in the following order of priority:
………………………
……………………..
I suggest the following as prospective caregivers for me in the event of need:
…………….
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. My personal beliefs and instructions as to such matters are on attached sheets. My agent shall appoint each of the following, only, however, if necessary: a conservator of my person, and a caregiver. He/she might find recommendations through the Social Service Department at Leisure World (949/597-4267), which currently lists 12 private conservators.
1.3 WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I 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 POSTDEATH AUTHORITY: My agents are authorized to make anatomical gifts, authorize an autopsy, or to direct disposition of my remains, as set forth below.
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 I 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: I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below:
[ ] (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
[ ] (b) Choice To Prolong Life
I 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 DIRECTIONS: I do not want to receive treatment, including nutrition and hydration, when the treatment will not give me a meaningful quality of life. I do not want my life to be prolonged under the following circumstances:
(a) If the treatment will leave me in a condition of permanent unconsciousness, such as an irreversible coma or a persistent vegetative state.
(b) If the treatment will leave me with complete, or nearly complete, loss of ability to think or communicate with others.
(c) If the treatment will leave me with only some ability to think and communicate with others, and the likely risks and burdens of such treatment outweigh the expected benefits. Risks, burdens and benefits include consideration of length of life, quality of life, financial costs, and my personal dignity and privacy.
When it comes to the three broad situations above, and only then, I give my agent the following powers:
To consent, refuse, or withdraw consent to any and all types of health care, meaning any care, treatment, service or procedure to maintain, diagnose or otherwise affect my physical or mental condition. It includes, but is not limited to, artificial respiration, nutritional support and hydration, medications, and cardiopulmonary resuscitation;
To have access to medical records and information to the same extent that I, in a normal state, would be entitled to, including the right to disclose the contents to others as appropriate for my health care;
To authorize my admission to or discharge (even against medical advice) from any hospital, nursing home, residential care, assisted living or similar facility or service;
To contract on my behalf for any health care related service or facility on my behalf, without my agent incurring personal financial liability for such contracts;
To hire and fire medical, social service, and other support personnel responsible for my care;
To authorize any medication or procedure intended to relieve pain, even though such use may lead to physical damage, addiction, or hasten (but not intentionally cause) my death;
To refuse to authorize any medication or procedure even though doing so may hasten (but not intentionally cause) my death;
To make anatomical gifts of part or all of my body for medical purposes, authorize an autopsy, and direct the disposition of my remains, to the extent permitted by law, consistent with the Willed Body Program of UCI (949) 824-6061 with which I am registered. They should be notified immediately upon my passing;
To take any other action necessary to, including (but not limited to) granting any waiver or release from liability required by any hospital, physician, or other health care provider; signing any documents relating to refusals of treatment or the leaving of a facility against medical advice; and pursuing any legal action in my name at the expense of my estate to force compliance with my wishes as determined by my agent, or to seek actual or punitive damages for the failure to comply.
PART 3
PRIMARY PHYSICIAN
(OPTIONAL)
3.1 I designate the following physician as my primary physician:
____________________________________________________________________
3.2 OPTIONAL: If the physician I 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:
_____________________________________________________________________
PART 4
4.1 EFFECT OF COPY: A copy of this form has the same effect as the original.
4.2 SIGNATURE: Sign and date the form here:
________________________, 2005. _____________________________________________
4.3 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 I 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 and Address of Witness) (Print Name and Address of Witness)
__________________________________ _____________________________________
(Signature of Witness) (Signature of Witness)
__________________________________ _____________________________________
(Date) (Date)
4.4 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)
AUTHORIZATION TO RELEASE HEALTH INFORMATION
I, _________________________________________________________________ ,
grant to my agent(s) under my advance health care directive the authority to advocate for my health care needs if I have been determined to lack capacity to make my own health care decisions.
- Pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 USC Section 1320d and 45 CFR Parts 160, 164, and the California Confidentiality of Medical Information Act (Civil Code Sections 56-56.37), I authorize all health care providers and covered entities to disclose to my agent(s) under my advance health care directive, at my agent’s request, all of my individually identifiable health and medical information and medical records regarding any past, present or future medical or mental health condition in the minimum amount necessary to advocate for my health care needs.
- I intend my agent to be dealt with by all my health care providers and covered entities, as required by HIPAA and California law, in the exact same way as I would be treated with respect to my rights regarding the use and disclosure of my identifiable protected health information or other medical records.
- I understand that:
- I have a right to receive a copy of this authorization.
- I may revoke or modify this authorization at any time by written notice delivered to and received by the health care provider.
- This authorization shall expire on the date of my death unless validly revoked prior to that date.
- Under California law, all recipients of protected health care information may not redisclose it except as required or permitted by law.
- The covered entity may not condition treatment, payment, enrollment, or eligibility for benefits on whether I sign an authorization unless the law allows conditions.
- There is the potential for information disclosed pursuant to this authorization to be subject to redisclosure by the recipient and no longer protected by HIPAA regulations.
Date: _______________________, 2005. __________________________________________
ATTACHED SHEETS
Info particular to al garner:
Remaining in my residence:
I wish to return home after any hospitalization or convalescent care as soon as practical. I wish to live there as long as it is practical to do so without endangering my physical or mental health and safety and to receive whatever assistance from household employees or personal caregivers may be necessary to permit me to do so. I prefer to pass away at home without lingering.
In the event my health care agent determines that appropriate household employees or personal caregivers are not available without putting my financial position or physical or mental health or safety at risk, I wish to live in the quietest, cleanest, best-run residence with the most fellow residents in the least restrictive atmosphere deemed appropriate by my health care agent as near as possible to my primary residence in order that I may visit with friends and neighbors to the degree my agent believes that I will benefit from such relationships.
Miscellaneous:
I think many people, in and out of medicine, can be more quiet, gentle, understanding and realistic. I seek control of my life as long as possible and when I cannot, I direct may agent to follow the guidelines set forth in Part 2 hereinabove regarding my treatment.
My health care agent(s), in the order of priority listed, shall have the power to appoint (a) one or more caregivers, and (c) if required, a conservator.
I think my health care agent should possibly get a 2nd opinion from a physician on major medical decisions, and get a 2nd opinion from the next available person on the list of health care agents on major decisions which are not medical.
I believe in the Hospice program, physician-assisted euthanasia for the terminally ill, and the Hemlock Society.
There are many aged people withering away in deplorable conditions. I will do anything to avoid that. I seek to maintain control of my affairs as long as practical.
I don’t want to be treated like a number at one extreme, nor fawned over at the other with patronizing baby-talk from someone with a degree in feel-good. No idealism, gloss over, pretend, denial, role-playing, superficiality, wishful thinking, superstition, religion or mysticism.
Ideally there should be some system that insures quality care for me, yet has incentives for my health care agent and caregivers to be efficient – such as their getting a portion of the money they save.
Preferably the caregivers should not be more than 15 years younger than me. He/she must be a non-smoker. No alcohol on the premises or in his/her car. Each resident of my house should probably use lightweight headphones for TVs and sound equipment. He/she should have everything outlined on paper before taking me to professionals and should, with permission, record important parts with a voice recorder and later enter them into a log. I prefer to go to doctors whose waiting rooms have no music or TVs. Some doctors will come to the home.
My residence should be aired out 5 hours a day daily in good weather, otherwise every few days. No fuss over food. I don’t want to hear about it, talk about it, rave about it, worship it or be told I HAVE to eat this and that by some chubby person. No cute excuses about sugary desserts, “treats”, “snacks”. No fattening food around me – only simple food. If healthy and low in salt, TV dinners are fine. I don’t think I want Meals on Wheels.
There is a booklet called YOUR WAY. To help caregivers, it asks patients what’s important. My answers are: controlling my affairs, beating the game, creativity, boiling things down to how-to checklists, collecting websites and articles, following the news, and supporting causes. Also history, New York City, nature, sentimental things, the New England Fall foliage, nostalgia, Americana, reunions, Class website, small things (as in the movies of jaque tati), working on my house, walking, and humor: Self-deprecation (Rodney Dangerfield, Tim Conway), imitations (Jonathan Winters), put-ons, spoof (Steve Martin, John Belushi), putdowns (Don Rickles), other (Laurel and Hardy).
On a sheet to be kept separately, list information needed when you pass away: Father, mother, and their birthplaces. Location of your combinations to safes, will, trust, durable power of attorney, health directive, birth certificate, checking account, savings account, banks, accountants, lawyers, credit cards, atm cards, deeds, insurance, mortgage co, safety deposit box, relatives, income tax preparer.
