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Advance Care Directives

Advance care planning documents allow you to communicate your healthcare preferences clearly and proactively.

Download AHCD Form
Download POLST Form

advanced health care directive

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 forms lets you do either or both of these things. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.

Instructions

Part 1 of this form lets you name another person 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 a different person to act for you if your first choice is not willing, able, or reasonably available to make decisions for you.

Unless you state otherwise in this form, your agent will have the right to:

  1. Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition.
  2. Select or discharge health care providers and institutions.
  3. Approve or disapprove diagnostic tests, surgical procedures, and programs of medication.
  4. Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care, including cardiopulmonary resuscitation.
  5. Donate your organs, tissues, and parts; authorize an autopsy, and direct disposition of remains.

However, your agent will not be able to commit you to a mental health facility, or consent to convulsive treatment, psychosurgery, sterilization or abortion for you.

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. You also can add to the choices you have made or write down 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.

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.

Part 1 — Power of Attorney for Health Care

Part 1 — Power of Attorney for Health Care

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 an employee of the health care institution where you are receiving care, unless your agent is related to you or is a coworker.

Designation of Agent:

I designate the following person as my agent to make health care decisions for me:

Address

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 alternate agent:

Address

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 I state here:

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.

OR

My agent’s authority to make health care decisions for me takes effect immediately.

Agent’s Obligation:

My agent must 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.

My agent is authorized to donate my organs, tissues, and parts, authorize an autopsy and direct disposition of my remains, except as I state here or in Part 3 of this form:

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 agent whom I have named.

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 agent whom I have named.

Part 2 — Instructions for Health Care

If you fill out this part of the form, you may strike any wording you do not want.

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:

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. degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits. (Initial here)

OR

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
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
(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:

Part 3 — Donation of Organs, Tissues, and Parts at Death (Optional)

Upon my death:

By initialing this line, and notwithstanding my choice in Part 2 of this form, I authorize my agent to consent to any temporary medical procedure necessary solely to evaluate and/or maintain my organs, tissues, and/or parts for purposes of donation.

OR

OR

My donation is for the following purposes (strike any of the following you do not want):

If you want to restrict your donation of an organ, tissue, or part in some way, please state your restriction on the following lines:

Warning:

I understand that tissue banks work with both nonprofit and for-profit tissue processors and distributors. It is possible that donated skin may be used for cosmetic or reconstructive surgery purposes. It is possible that donated tissue may be used for transplants outside of the United States.

My donated skin may be used for cosmetic surgery purposes.
My donated tissue may be used for applications outside of the United States.
My donated tissue may be used by for-profit tissue processors and distributors.

Statement:

If I leave Part 3 blank, it is not a refusal to make a donation. My state-authorized donor registration should be followed, or, if none, my agent may make a donation upon my death. If no agent is named above, I acknowledge that California law permits an authorized individual to make such a decision on my behalf. (To state any limitation, preference, or instruction regarding donation, please use the lines above or on page 3 of this form.)

Part 4 — Primary Physician (Optional)

I designate the following physician as my primary physician:

Address

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:
Address

Part 5 — Signature

The form must be signed by you and by two qualified witnesses, or acknowledged before a notary public.

Signature:

Sign and date the form here:

Date: Time: AM / PM
Clear Signature
Address
Statement of Witnesses:

First Witness:

Address
Date: Time: AM / PM
Clear Signature

Second Witness:

Address
Date: Time: AM / PM
Clear Signature

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.

Date: Time: AM / PM
Clear Signature

Notary:

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 the document.

YOU MAY USE THIS CERTIFICATE OF ACKNOWLEDGMENT BEFORE A NOTARY PUBLIC INSTEAD OF THE STATEMENT OF WITNESSES.

On (date)
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.

Certify:

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.

Clear Signature

Part 6 — Special Witness Requirement

If you are a patient in a skilled nursing facility, the patient advocate or ombudsman must sign the following statement:

Statement of Patient Advocate or Ombudsman

I 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: Time: AM / PM
Clear Signature
Address

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTHCARE PROFESSIONALS AS NECESSARY

Physician Orders for Life-Sustaining Treatment (POLST)

First follow these orders, then contact Physician/NP/PA. A copy of the signed POLST form is a legally valid physician order. Any section not completed implies full treatment for that section. POLST complements an Advance Directive and is not intended to replace that document

A: CARDIOPULMONARY RESUSCITATION (CPR): (Check One)
If patient has no pulse and is not breathing. If patient is NOT in cardiopulmonary arrest, follow orders in Sections B and C.
B: MEDICAL INTERVENTIONS: (Check One)
If patient is found with a pulse and/or is breathing.
C: ARTIFICIALLY ADMINISTERED NUTRITION: (Check One)
D: INFORMATION AND SIGNATURES:
Discussed with:
Advance Directive dated

Signature of Physician / Nurse Practitioner / Physician Assistant (Physician/NP/PA)

My signature below indicates to the best of my knowledge that these orders are consistent with the patient’s medical condition and preferences

Clear Signature

Signature of Patient or Legally Recognized Decisionmaker

I am aware that this form is voluntary. By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form.

Clear Signature
Mailing Address (street/city/state/zip):
Your POLST may be added to a secure electronic registry to be accessible by health providers, as permitted by HIPAA.

SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGE

*Form versions with effective dates of 1/1/2009, 4/1/2011, 10/1/2014 or 01/01/2016 are also valid.

HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY

Patient Information

Gender
NP/PA’s Supervising Physician
Preparer Name (if other than signing Physician/NP/PA)

Additional Contact:

Directions for Health Care Provider

Completing POLST

  • Completing a POLST form is voluntary. California law requires that a POLST form be followed by healthcare providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed by a physician, or a nurse practitioner (NP) or a physician assistant (PA) acting under the supervision of the physician, who will issue appropriate orders that are consistent with the patient’s preferences.
  • POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to ensure consistency, and update forms appropriately to resolve any conflicts.
  • POLST must be completed by a health care provider based on patient preferences and medical indications.
  • A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest available relative, or person whom the patient’s physician/NP/PA believes best knows what is in the patient’s best interest and will make decisions in accordance with the patient’s expressed wishes and values to the extent known.
  • A legally recognized decisionmaker may execute the POLST form only if the patient lacks capacity or has designated that the decisionmaker’s authority is effective immediately.
  • To be valid a POLST form must be signed by (1) a physician, or by a nurse practitioner or a physician assistant acting under the supervision of a physician and within the scope of practice authorized by law and (2) the patient or decisionmaker. Verbal orders are acceptable with follow-up signature by physician/NP/PA in accordance with facility/community policy.
  • If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form.
  • Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A copy should be retained in patient’s medical record, on Ultra Pink paper when possible.

Using POLST

  • Any incomplete section of POLST implies full treatment for that section.

Section A:

  • If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions should be used on a patient who has chosen “Do Not Attempt Resuscitation.”

Section B:

  • When comfort cannot be achieved in the current setting, the patient, including someone with “Comfort-Focused Treatment,” should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).
  • Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway pressure (BiPAP), and bag valve mask (BVM) assisted respirations.
  • IV antibiotics and hydration generally are not “Comfort-Focused Treatment.”
  • Treatment of dehydration prolongs life. If a patient desires IV fluids, indicate “Selective Treatment” or “Full Treatment.”
  • Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel.

Reviewing POLST

It is recommended that POLST be reviewed periodically. Review is recommended when:

  • The patient is transferred from one care setting or care level to another, or
  • There is a substantial change in the patient’s health status, or
  • The patient’s treatment preferences change.

Modifying and Voiding POLST

  • A patient with capacity can, at any time, request alternative treatment or revoke a POLST by any means that indicates intent to revoke. It is recommended that revocation be documented by drawing a line through Sections A through D, writing “VOID” in large letters, and signing and dating this line.
  • A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician/NP/PA, based on the known desires of the patient or, if unknown, the patient’s best interests.

This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force. For more information or a copy of the form, visit www.caPOLST.org.

SEND FORM WITH PATIENT WHENEVER TRANSFERRED OR DISCHARGED

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