California Advance Health Care Directive
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- Claire Jennings
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1 Califria Advace Health Care Directive This frm lets yu have a say abut hw yu wat t be treated if yu get very sick. This frm has 3 parts. It lets yu: Part 1: Chse a health care aget. A health care aget is a pers wh ca make medical decisis fr yu if yu are t sick t make them yurself. Part 2: Make yur w health care chices. This frm lets yu chse the kid f health care yu wat. This way, thse wh care fr yu will t have t guess what yu wat if yu are t sick t tell them yurself. Part 3: Sig the frm. It must be siged befre it ca be used. Yu ca fill ut Part 1, Part 2, r bth. Fill ut ly the parts yu wat. Always sig the frm i Part 3. 2 witesses eed t sig page 10 r a tary public page 11. YOUR NAME: G t the ext page 1
2 Califria Advace Health Care Directive If yu ly wat a health care aget g t Part 1 page 3. If yu ly wat t make yur w health care chices g t Part 2 page 6. If yu wat bth the fill ut Part 1 ad Part 2. Always sig the frm i Part 3 page 9. 2 witesses eed t sig page 10 r a tary public page 11. What d I d with the frm after I fill it ut? Share the frm with thse wh care fr yu: dctrs urses scial wrkers family & frieds health care aget What if I chage my mid? Fill ut a ew frm. Tell thse wh care fr yu abut yur chages. Give the ew frm t yur health care aget ad dctr. What if I have questis abut the frm? Brig it t yur dctrs, urses, scial wrkers, health care aget, family r frieds t aswer yur questis. What if I wat t make health care chices that are t this frm? 2 Write yur chices a piece f paper. Keep the paper with this frm. Share yur chices with thse wh care fr yu.
3 Califria Advace Health Care Directive PART 1 Chse yur health care aget The pers wh ca make medical decisis fr yu if yu are t sick t make them yurself. Whm shuld I chse t be my health care aget? A family member r fried wh: is at least 18 years ld kws yu well ca be there fr yu whe yu eed them yu trust t d what is best fr yu ca tell yur dctrs abut the decisis yu made this frm Yur aget cat be yur dctr r smee wh wrks at yur hspital r cliic, uless he/she is a family member. What will happe if I d t chse a health care aget? If yu are t sick t make yur w decisis, yur dctrs will ask yur clsest family members t make decisis fr yu. If yu wat yur aget t be smee ther tha family, yu must write his r her ame this frm. What kid f decisis ca my health care aget make? Agree t, say t, chage, stp r chse: dctrs, urses, scial wrkers hspitals r cliics medicatis, tests, r treatmets what happes t yur bdy ad rgas after yu die Yur aget will eed t fllw the health care chices yu make i Part 2. G t the ext page 3
4 Part 1: Chse yur health care aget Califria Advace Health Care Directive Other decisis yur aget ca make: Life supprt treatmets medical care t try t help yu live lger CPR r cardipulmary resuscitati cardi = heart pulmary = lugs resuscitati = t brig back This may ivlve: pressig hard yur chest t keep yur bld pumpig electrical shcks t jump start yur heart medicies i yur veis Breathig machie r vetilatr The machie pumps air it yur lugs ad breathes fr yu. Yu are t able t talk whe yu are the machie. Dialysis A machie that cleas yur bld if yur kideys stp wrkig. Feedig Tube A tube used t feed yu if yu cat swallw. The tube is placed dw yur thrat it yur stmach. It ca als be placed by surgery. Bld trasfusis T put bld i yur veis. Surgery Medicies Ed f life care if yu might die s yur health care aget ca: call i a spiritual leader decide if yu die at hme r i the hspital Shw yur health care aget this frm. Tell yur aget what kid f medical care yu wat. 4 G t the ext page
5 Part 1: Chse yur health care aget Califria Advace Health Care Directive Yur Health Care Aget I wat this pers t make my medical decisis. first ame last ame street address city state zip cde ( ) ( ) hme phe umber wrk phe umber If the first pers cat d it, the I wat this pers t make my medical decisis. first ame last ame street address city state zip cde ( ) ( ) hme phe umber wrk phe umber Put a X ext t the setece yu agree with. My health care aget ca make decisis fr me right after I sig this frm. My health care aget will make decisis fr me ly after I cat make my w decisis. Yu may write dw yur health care chices this frm. Hw d yu wat yur health care aget t fllw these chices? Put a X ext t the e setece yu mst agree with. I wat my health care aget t wrk with my dctrs ad t use her/his best judgmet. It is OK fr my aget t fllw my health care chices this frm as a geeral guide. Eve thugh it is OK t fllw my chices as a geeral guide, there are sme chices I d t wat chaged: I wat my health care aget t fllw my health care chices this frm exactly. I ever wat my aget t chage my chices, eve if the dctrs thik this is t gd fr me. T make yur w health care chices g t Part 2 the ext page. T sig this frm g t Part 3 page 9. 5
6 Califria Advace Health Care Directive PART 2 Make yur w health care chices Write dw yur chices s thse wh care fr yu will t have t guess. Thik abut what makes yur life wrth livig. r My life is ly wrth livig if I ca: Put a X ext t all the seteces yu mst agree with. m talk t family r frieds m wake up frm a cma m feed, bathe, r take care f myself m be free frm pai m live withut beig hked up t machies m I am t sure My life is always wrth livig matter hw sick I am If I am dyig, it is imprtat fr me t be: at hme i the hspital I am t sure Is religi r spirituality imprtat t yu? yes If yu have e, what is yur religi? What shuld yur dctrs kw abut yur religi r spirituality? If yu are sick, yur dctrs ad urses will always try t keep yu cmfrtable ad free frm pai. 6 G t the ext page
7 Part 2: Make yur w health care chices Califria Advace Health Care Directive Life supprt treatmets are used t try t keep yu alive. These ca be CPR, a breathig machie, feedig tubes, dialysis, bld trasfusis, r medicie. Put a X ext t the e chice yu mst agree with. Please read this whle page befre yu make yur chice. If I am s sick that I may die s: Try all life supprt treatmets that my dctrs thik might help. If the treatmets d t wrk ad there is little hpe f gettig better, I wat t stay life supprt machies. r Try all life supprt treatmets that my dctrs thik might help. If the treatmets d t wrk ad there is little hpe f gettig better, I d t wat t stay life supprt machies. r r r r Try all life supprt treatmets that my dctrs thik might help but t these treatmets. Mark what yu d t wat. m CPR m feedig tube m dialysis m bld trasfusi m breathig machie m medicie m ther treatmets I d t wat ay life supprt treatmets. I wat my health care aget t decide fr me. I am t sure. G t the ext page 7
8 Part 2: Make yur w health care chices Califria Advace Health Care Directive Yur dctrs may ask abut rga dati ad autpsy after yu die. Please tell us yur wishes. Put a X ext t the e chice yu mst agree with. Datig (givig) yur rgas ca help save lives. I wat t date my rgas. Which rgas d yu wat t date? m ay rga m ly I d t wat t date my rgas. I wat my health care aget t decide. I am t sure. A autpsy ca be de after death t fid ut why smee died. It is de by surgery. It ca take a few days. I wat a autpsy. I d t wat a autpsy. I wat a autpsy if there are questis abut my death. I wat my health care aget t decide. I am t sure. What shuld yur dctrs kw abut hw yu wat yur bdy t be treated after yu die? 8 G t Part 3 the ext page t sig this frm
9 Califria Advace Health Care Directive PART 3 Sig the frm Befre this frm ca be used, yu must: sig this frm have tw witesses sig the frm If yu d t have witesses, a tary public must sig page 11. A tary public s jb is t make sure it is yu sigig the frm. Sig yur ame ad write the date. sig yur ame / / date prit yur first ame prit yur last ame address city state zip cde Yur witesses must: be ver 18 years f age kw yu see yu sig this frm Yur witesses cat: be yur health care aget be yur health care prvider wrk fr yur health care prvider wrk at the place that yu live (if yu live i a ursig hme g t page 12) Als, e witess cat: be related t yu i ay way beefit fiacially (get ay mey r prperty) after yu die Witesses eed t sig their ames the ext page. If yu d t have witesses, take this frm t a tary public ad have them sig page 11. 9
10 Part 3: Sig the frm Califria Advace Health Care Directive Witess #1 sig yur ame Have yur witesses sig their ames ad write the date By sigig, I prmise that siged this frm while I watched. (ame) He/she was thikig clearly ad was t frced t sig it. I als prmise that: I kw him/her r this pers culd prve wh he/she was I am 18 years r lder I am t his/her health care aget I am t his/her health care prvider I d t wrk fr his/her health care prvider I d t wrk where he/she lives Oe witess must als prmise that: I am t related t his/her by bld, marriage, r adpti I will t beefit fiacially (get ay mey r prperty) after he/she dies / / date prit yur first ame prit yur last ame address city state zip cde Witess #2 sig yur ame / / date prit yur first ame prit yur last ame address city state zip cde 10 Yu are w de with this frm. Share this frm with yur dctrs, urses, scial wrkers, frieds, family, ad health care aget. Talk with them abut yur chices.
11 Part 3: Sig the frm Califria Advace Health Care Directive NOTARY PUBLIC Take this frm t a tary public ly if tw witesses have t siged this frm. Brig pht I.D. (driver s licese, passprt, etc.) Yu are w de with this frm. Share this frm with yur dctrs, urses, scial wrkers, frieds, family, ad health care aget. Talk with them abut yur chices. 11
12 Califria Advace Health Care Directive Fr Califria Nursig Hme Residets ONLY Give this frm t yur ursig hme directr ly if yu live i a ursig hme. Califria law requires ursig hme residets t have the ursig hme mbudsma as a witess f advace directives. statemet f the patiet advcate r Ombudsma I declare uder pealty f perjury uder the laws f Califria that I am a patiet advcate r mbudsma as desigated by the State Departmet f Agig ad that I am servig as a witess as required by Secti 4675 f the Prbate Cde. sig yur ame / / date prit yur first ame prit yur last ame address city state zip cde This advace directive is i cmpliace with the Califria Prbate Cde, Secti This wrk is licesed uder the Creative Cmms Attributi-NCmmercial-ShareAlike Licese. T view a cpy f this licese, 12 visit r sed a letter t Creative Cmms, 559 Natha Abbtt Way, Stafrd, Califria 94305, USA. Revised 1/18/2010 Desiged by Rebecca Sudre, MD & Mahat Papartassee fr the Sa Fracisc Departmet f Public Health
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