POWER OF ATTORNEY FOR HEALTH CARE AND BURIALEveryone, no matter what age, should have this form filled out with your will so that YOUR WISHES
are followed. This is the "elderly doctor counseling" in the Health Reform Bill designated for
every five years with your primary physician. It is NOT about euthanasia - it is about your desires to be
followed, not some stranger or a burden on your family agonizing over what it is you would want.
Having this form filled out makes it clear without question. This particular form is for California - please
do a search under HEALTH CARE DIRECTIVE for your particular state so you have the correct form and
give family members the CHEAP FUNERAL they probably would PREFER as they LOVE YOU A LOT.
( Especially as my four kids are POOR. I DO NOT WANT A FUNERAL OR A COFFIN!You have the right to give instructions about your own health care. You also have the right to name
NO UNDERTAKERS, no Costly Crypt, NONE OF IT! I want a California Hippie Burial,
die as I lived. I didn't give my kids headaches when I was alive, I sure don't want to start
when I"m dead. I want my children to let the city haul my body away ..pauper's burial
and a 400$ price tag if that! They can escape it if they claim indigency. Not that I dont
want to be remembered. I am pre-mailing envelopes of my lovely hair, one for each,
and one of my artware vases, they can put THAT on the mantle.
Nothing disgusting like ashes, fergawdsakes! Anyone wants to talk to me, no driving to
Forest Lawn, no costly gasoline, just talk to me right there on the chimney. Hey,
one of you can have my oil paint portrait by Sigrid Gurie, costar of GARY COOPER in MARCO POLO.
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 express an intention to donate your bodily organs and tissues following your
death.Part 4 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 this advance health care directive or replace this form at any time.
* * * * * * * * * * * * * * * * *
PART 1
POWER OF ATTORNEY FOR HEALTH CARE(1.1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care
decisions for me:________________________________________________________
(name of individual you choose as agent)________________________________________________________
(address) (city) (state) (zip code)________________________________________________________
(home phone) (work phone)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 first alternate agent:________________________________________________________
(name of individual you choose as first alternate agent)________________________________________________________
(address) (city) (state) (zip code)________________________________________________________
(home phone) (work phone)OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able, or
reasonably available to make a health care decision for me, I designate as my second alternate agent:________________________________________________________
(name of individual you choose as second alternate agent)________________________________________________________
(address) (city) (state) (zip code)________________________________________________________
(home phone) (work phone)(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, except as I state here:________________________________________________________
________________________________________________________
________________________________________________________
(Add additional sheets if needed.)(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 agent is authorized to make anatomical gifts, authorize an
autopsy, and direct disposition of my remains, except as I state here or in Part 3 of this form:
________________________________________________________
________________________________________________________
________________________________________________________
(Add additional sheets if needed.)(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 CAREIf 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 WISHES: (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:
________________________________________________________
________________________________________________________
________________________________________________________
(Add additional sheets if needed.)PART 3
DONATION OF ORGANS AT DEATH
(OPTIONAL)(3.1) Upon my death (mark applicable box):
(a) I give any needed organs, tissues, or parts, OR
(b) I give the following organs, tissues, or parts only.
________________________________________________________(c) My gift is for the following purposes (strike any of the following you do not want):
(1) Transplant
(2) Therapy
(3) Research
(4) EducationPART 4
PRIMARY PHYSICIAN
(OPTIONAL)(4.1) I designate the following physician as my primary physician:
________________________________________________________
(name of physician)________________________________________________________
(address) (city) (state) (zip code)________________________________________________________
(phone)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:________________________________________________________
(name of physician)________________________________________________________
(address) (city) (state) (zip code)________________________________________________________
(phone)* * * * * * * * * * * * * * * * *
PART 5
(5.1) EFFECT OF COPY: A copy of this form has the same effect as the original.
(5.2) SIGNATURE: Sign and date the form here:
______________ _______________________________
(date) (sign your name)_______________________________
(print your name)_______________________________
(address)_______________________________
(city) (state) (zip)(5.3) 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 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) (print name)__________________________ __________________________
(address) (address)__________________________ __________________________
(city) (state) (zip) (city) (state) (zip)__________________________ __________________________
(signature of witness) (signature of witness)__________________________ __________________________
(date) (date)(5.4) 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)PART 6
SPECIAL WITNESS REQUIREMENT(6.1) The following statement is required only if you are a patient in a skilled nursing facility--a health
care facility that provides the following basic services: skilled nursing care and supportive care to
patients whose primary need is for availability of skilled nursing care on an extended basis. 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) (sign your name)_______________________________
(print your name)_______________________________
(address)_______________________________
(city) (state) (zip)
Other Forms You May Need
California Durable Power of Attorney for Health Care
California General Durable Power of Attorney for Property & Finances (Immediate)
California General Durable Power of Attorney for Property & Finances (Upon Disability)
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