Instructions for completing the California Advance Health Care Directive form
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1 Instructions for completing the California Advance Health Care Directive form An Advance Health Care Directive has 3 parts: Part 1: The health care agent. A health care agent is a person who can make medical decisions for you if you are too sick to make them yourself. Part 2: Health care choices. You can have a say about how you are treated. Part 3: Signatures and Witnesses. It must be signed and witnessed to be legally binding. Getting Started Go to Page 1, Part 1 1A: Print your first name, last name, date of birth, address, city, state, and ZIP code so it is clear who is making this directive. Whom should I choose as my health care agent? Choose a family member or friend who: is at least 18 years old knows you well can be there for you when you need them you trust to do what is best for you can tell your doctors about the decisions you would want made Your agent cannot be your doctor or someone who works at your hospital or clinic where you get health care, unless they are a family member or your co-worker. Advance Health Care Directive Form Instructions 1
2 Go to 1B 1B: Write in the name of your agent. Your agent is the person who you want to make medical decisions for you In case the first person cannot do it, write in who should help make your medical decisions. Your health care agent can start helping with your medical decisions right away; or you can ask that they get involved only if you cannot make your own decisions. Go to 1C 1C: If you want your agent to start right away place an X in the first box and sign your initials in the space. or, if you want your agent to start only when you cannot make your own decisions, place an X in the second box and sign your initials in the space. What kind of decisions can my health care agent make? Your agent can agree to, say no to, change, stop or choose: doctors, nurses, social workers hospitals or clinics medical treatment (including artificial feeding), medications or tests what happens to your body and organs after you die If you do not want your agent to be able to make all these kinds of decisions, this is probably not the right advance health care directive form for you. Becoming your agent does not mean that he/she assumes financial responsibility for you. Advance Health Care Directive Form Instructions 2
3 Go to Page 2, 1D 1D: Sign your initials to indicate that you understand that your agent will be able to make all these kinds of decisions. Is there someone you DON T want to make the decisions? Is there someone who might argue with your agent and you don t want that person to interfere with your agent s decisions? Go to Page 2, 1E 1E: If there is no such person, check the No Exclusions box and sign your initials. If there is such a person, you can exclude that person from making health care decisions for you by writing their name in the space and signing your initials. After Your Death Your health care agent can: decide if any of your organs will be donated. Donated organs can save lives. request, consent to, or refuse an autopsy. An autopsy can be done after death to find out why someone died. It is done by surgery. It can take a few days. decide what happens to your body, such as burial or cremation. Go to Page 2, 1F 1F: If you want to leave these decisions to your agent after your death, check the box No Exceptions and sign your initials. If you do not want your agent to make these decisions, you should put in writing your own decisions about what should happen to your body after death. Advance Health Care Directive Form Instructions 3
4 What if I want to provide specific health care instructions that are not on the AHCD form? Go to Page 2, Part 2 HEALTH CARE INSTRUCTIONS 2A: You may write extra pages in your own words, or use a values history form to guide your agent in making difficult decisions Attach the extra pages to the Advance Health Care Directive. Sign and date the attachments and have them witnessed or notarized at the same time you have your form witnessed or notarized. Talk to your agent(s) and doctor(s) about your specific health care instructions to be sure they understand your wishes. 2B: Some personal care decisions are not automatically given to your health care agent. If you want your health care agent to be able to make personal care decisions, initial this paragraph. Part 3: SIGNING THE FORM You must sign the form, and you will need witnesses or a notary public to sign too. Go to Page 3, Part 3 3: Sign and date the document in the presence of the witnesses or the notary Your witnesses must: be over 18 years of age. know who you are. believe that you are the one who signed the form. Your witnesses cannot: be your doctor, nurse, or social worker. work at the place that you live, if you live in a care facility. Advance Health Care Directive Form Instructions 4
5 The person you chose as your agent or alternate agent CANNOT be a witness Only one of the witnesses can be related to you by blood, marriage or adoption, be named in your will, or be someone who would benefit from your estate. Go to Page 3, 4A Witnesses Signatures 4A: Have the witnesses read the witness statements before they sign. 4B: One witness must be someone other than family and must not benefit financially (get any money or be named in your will) after you die. Have that person sign again at 4B If you live in a nursing home: You will need an additional witness. California law requires nursing home residents to have the nursing home ombudsman as a witness of advance directives. In addition to the ombudsman, you will need either a notary or one other witness who will meet the qualifications listed above. Go to Page 4, 4C 4C: If you do not live in a nursing home, check the box next to I do not reside in a skilled nursing facility and sign your initials. What do I do with the form once it is all filled out? Keep the original yourself. Make copies of the form to share with those who care for you. Keep a list of who has copies. family friends doctors nurses social workers What if I change my mind? Complete a new form. Give out copies of the new form to all the same people. Advance Health Care Directive Form Instructions 5
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