CA Pad Insns

5088.
01
Revised 03/27/03
Advance
Health Care
Directives
© 2000 - Protection & Advocacy, Inc.
Protection & Advocacy, Inc.

100 Howe Avenue, Suite 185-N
Sacramento CA 95825
1-800-776-5746
Blank page
ADVANCE HEALTH CARE DIRECTIVE
GENERAL INFORMATION
1. What is an Advance Directive?
An Advance Directive provides a way for people to direct their own
healthcare even when they are in a coma, have dementia or are mentally
incapacitated or unable to communicate. A person can use an Advance
Directive to spell out her wishes regarding physical and mental healthcare
and to select someone to make health care decisions when she is unable
to do so.
In California, an Advance Directive is made of up two parts, (1)

Appointment of an Agent for Healthcare and (2) Individual Health Care
Instructions. A person may choose to complete either one or both of these
parts. Either part is legally binding by itself.
2. What is a Healthcare Agent?

A person may use her Advance Directive to appoint a Healthcare Agent. A
Healthcare Agent is responsible for making healthcare decisions should the
person lose the ability to make these decisions for herself. A Healthcare
Agent is responsible for carrying out the person’s wishes as she has
expressed them in her Advance Directive or in discussions with the Agent.
It is not necessary to name a Healthcare Agent in order to complete an

Advance Directive. If the person has not chosen a Healthcare Agent, the
healthcare provider is still required to follow the person’s wishes, as
expressed in the Individual Healthcare Instructions.
If both parts of the Advance Directive are filled out, the Healthcare Agent
must follow the specific wishes spelled out in the second part of the
document which is called the Individual Healthcare Instructions.
A single gender (female) is used to simplify the writing style, but all information applies to both men and women.
General Information Page 1 of 6

3. What are Individual Healthcare Instructions?
Individual Healthcare Instructions are the way in which a person can tell her
doctor, family or Agent what her decisions are regarding physical or mental
health treatment. Individual Healthcare Instructions are verbal or written
directions about health care. A person can use Individual Healthcare
Instructions to let her healthcare provider know what she wants done and
under what circumstances. This may include agreeing to certain
treatments or refusing specific treatments or services.
4. What can an Advance Directive do for a person with a

psychiatric disability?
A person with a psychiatric disability can benefit from having an Advance
Directive in a number of ways:
An Advance Directive can empower the person to make her

treatment choices known in the event she needs mental health
treatment and is found to be incapable of making healthcare
decisions.
An Advance Directive can improve communication between the
person and her doctor. Completing an Advance Directive is a good
way to open up discussion with healthcare providers about treatment
plans and the full spectrum of choices in treatment.
An Advance Directive can help the person prevent clashes with family
members and/or healthcare providers over treatment during a crisis
by allowing those discussions to take place when a person is filling
out her Advance Directive.
Completing an Advance Directive creates an opportunity for the
person to discuss her wishes in detail with family and/or friends. This
may help family and/or friends more effectively advocate for the
person when she is unable to advocate for herself and to advocate in
ways that reflect the person’s wishes.
An Advance Directive may prevent forced treatment.
An Advance Directive may reduce the need for long hospital stays.

5. Who can fill out an Advance Directive?
Any person 18 years or older who has the “capacity” to make health care
decisions may fill out an Advance Directive. “Capacity” to make healthcare
decisions means the person understands the nature and consequences of
the proposed healthcare, including the possible risks and benefits and is
able to make and communicate decisions about that healthcare. Legally, a
person is assumed to be competent unless proven otherwise.
6. How does an Advance Directive become official?

An Advance Directive must contain all of the following to be official:
A statement of the person’s intent to create an Advance Directive.

The signature of the person writing the Advance Directive
The signatures of either two witnesses or a notary public
The date the Advance Directive was signed.
7. When does an Advance Directive go into effect?

An Advance Directive only goes into effect when the person’s primary
physician decides that the person does not have the “capacity” to make her
own healthcare decisions. This means the physician believes that the
person is not able to understand the nature and consequences of proposed
healthcare or is not able to make or communicate her healthcare decisions.
The fact that a person has been admitted to a mental health facility does
not, in itself, mean that the person lacks capacity to make her own
healthcare decisions.
The Advance Directive is no longer in effect as soon as the person regains

the capacity to make her own healthcare decisions.
8. Who can help with filling out an Advance Directive?

Writing an Advance Directive can sometimes seem confusing or
complicated. If a person needs help writing her Advance Directive, she
should ask someone who respects her right to make these decisions for
herself and will help without pressuring her to make one decision or
another.

It also a good to ask someone who is knowledgeable or experienced in
writing Advance Directive to help. The Office of Medi-Cal Ombudsman
Services for Mental Health can help people in finding someone nearby to
answer questions and assist in writing Advance Directives. The telephone
number for Ombudsman Services for Mental Health is (800) 896-4042.
9. Is a Healthcare Agent necessary?

No, a person does not have to name a Healthcare Agent in order to write a
valid Advance Directive. Someone who does not have a trusted family
member or friend may choose not to name a Healthcare Agent. If the
person does not have a Healthcare Agent, her healthcare provider must
still follow her wishes as expressed in her Individual Healthcare
instructions.
However, there are good reasons to name a Healthcare Agent. A

Healthcare Agent can advocate for the person when she is unable to
advocate for herself and can ensure that the person’s choices are
respected. A Healthcare Agent can also contact others for assistance in
enforcing the Advance Directive if the person’s choices are being ignored.
This is why it is so important for the person to choose only someone she
knows and trusts to be her Healthcare Agent.
Whether or not to name an Agent and who to name as Agent are two of the
most important decisions a person will have to make when writing an
Advance Directive.
10. What happens when a person wants to change an Individual

Healthcare Instruction?
The requirements for changing any Healthcare Instruction are the same as
those for completing an Advance Directive.
To change an Individual Healthcare Instruction, the person must
be at least 18 years old,

be acting freely and without pressure from anyone, and
have the “capacity” to make healthcare decisions.

A person can change an Individual Healthcare Instruction by writing a new
Advance Directive with the changes in it that she wants to make. If the
person writes a new Advance Directive she must take all the same steps
she did in writing the first Advance Directive, including having it witnessed.
A person can also revoke their Advance Directive orally, by telling their
healthcare provider that they no longer want either the entire document or
any parts of it enforced.
11. Who should have a copy of the Advance Directive?

The person should keep a copy of the Advance Directive for herself in a
place that is safe, but easily accessible.
The person should give a copy of the Advance Directive to her Agent if the
she has one. The Agent’s job is to make sure that the person’s decisions
are known and followed. To do this, the Agent must have a copy of the
Advance Directive that appoints her as the person’s Agent.
Each of the person’s healthcare providers should have a copy of the

Advance Directive and are legally required to place the Advance Directive
in the person’s medical records. This is important because the healthcare
provider cannot follow the person’s Individual Healthcare Instructions
unless they know what those instructions are. If the person does not have
an Agent or the Agent is unavailable, the healthcare provider will still know
what the wishes are if the document includes Individual Healthcare
Instructions.
The person should keep track of who has a copy of her Advance Directive.
If the patient decides to change or revoke (cancel) her designation of an
Agent or any individual healthcare instruction, she should let everyone who
has a copy of the Advance Directive know about the change/revocation to
avoid confusion.
12. Does a healthcare provider have to follow an Advance Directive?

Yes. Healthcare providers must follow both the person’s Individual
Healthcare Instructions and the decisions made on the person’s behalf by
her Agent.

13. Who can help if an Advance Directive is ignored/not followed?
If a healthcare provider refuses to follow the person’s Individual Healthcare
Instructions or refuses to comply with the decisions of the person’s Agent,
contact the county patients’ rights advocate and/or Protection and
Advocacy Incorporated (PAI). PAI and the county patients’ rights advocate
can work with the person or her Agent to make sure that the Advance
Directive is followed.
The telephone number for Protection and Advocacy, Inc is (800) 776-5746
and the telephone numbers for county patients’ rights advocate are posted
on the walls in all inpatient mental health facilities.

ADVANCE HEALTH CARE DIRECTIVE
EXPLANATION OF TERMS
FOR ADVANCE DIRECTIVES
The first part of your Advance Health Care Directive is written to inform the
reader of the Codes in both federal and state law that apply to the Advance
Directives you have written.
The listing of specific codes at the end of paragraphs is included so that

people can check them out, if they wish. Mostly, attorneys and health care
providers need to know these; consumers may go to the regulations listed if
they want to become better informed of their rights.
Some important legal terms in this section are:
1. Capacity – in this document, “capacity” refers to your ability to

understand, make and communicate your healthcare decisions; when
you are determined to “lack capacity” to do this is when the Advance
Directive goes into effect.
2. Duration – in California there is no automatic time limit on an

Advance Directive. Unless you state a specific date when you want
your document to expire, your Advance Directive stays in effect until
you decide to revoke it.
3. Revocability – in California you have the right under the law to say all
or any part of your Advance Directive is no longer binding.
4. Liability – in California health care providers can be sued for

“damages” (including fines and attorney’s fees) if they are found to
have failed to follow an Advance Health Care Directive.
5. Immunity – In California health care providers who are following an

Advance Directive in good faith are protected from being prosecuted
for a crime and from being sued for complying with the Advance
Directive.
Explanation of Terms Page 1 of 4

6. Discrimination – in California no one can make you have an Advance
Health Care Directive, or take away your right to have one, as a
condition for giving you health care, or admitting you to a place of
treatment, or providing you with insurance.
PART I: APPOINTMENT OF AN AGENT FOR HEALTH CARE
7. Health Care Agent – This is the person you choose to speak for you
and assert your health care decisions. Although you do not have to
choose an agent under California law, you may want to choose
someone who is willing to represent your wishes with regard to your
health treatment.
8. Conservator – this is someone whom the court may appoint to

oversee your affairs and make treatment decisions if you are
determined by the court to be unable to provide for your own basic
needs due to a mental disorder. You may want to identify someone
whom you prefer to be your conservator, in case the court decides to
do this.
PART II(a): STATEMENT OF INDIVIDUAL MENTAL HEALTH CARE

INSTRUCTIONS
9. Incapacity – this is another way of saying that you “lack capacity.” It

means you are not able to make or communicate your own health
care decisions at a particular time.
10. Treatment Facility – this would be any licensed place that is permitted
by law to provide psychiatric care on a 24-hour basis. It is often a
hospital.
11. Primary Physician – for the purposes of this section, this is the
medical doctor who has been identified by you as the one who has
first responsibility for providing your mental health care.

12. Emergency Situations – these are the kinds of crises that mental
health treatment facilities often see as justifying the use of such
methods as seclusion and restraint in order to control you.
a. Seclusion – a method of control that removes you and isolates you by

making you stay in a separate area.
b. Restraint – a method of control that physically limits your ability to

move.
13. Side Effects – the usually unpleasant or destructive things that may
happen to your body when you take certain medications.
a. Tardive Dyskinesia – movements of the face, hands, etc. that are not
able to be stopped at will that are the side effects of taking certain
medications.
b. Motor Restlessness – being unable to stop yourself from moving as a

side effect of taking certain medications.
c. Muscle/Skeletal Rigidity – extreme stiffness that is a side effect of

taking certain medications.
d. Neuroleptic Malignant Syndrome – the name given to a group of

sometimes life-threatening side effects to certain medications.
14. Electroconvulsive Therapy – sometimes called ECT or “shock

treatments,” this involves the use of electricity to provoke controlled
brain seizures, and is sometimes used in the treatment of depression.
15. Drug Trials – this is the use of people as subjects of research for the
testing of new medications.
PART II(b): INDIVIDUAL PHYSICAL HEALTH CARE INSTRUCTIONS
16. Life Sustaining Treatment – this is the term doctors and hospitals use
to describe the technology and machinery that has been invented to
prolong life when otherwise a person would die.

17. Persistent Vegetative State – this is the term used to describe a
human being whose ability to function has been severely reduced,
who is being kept alive on machines.
18. Anatomical Gift – this is the donation of all or part of your body for
medical or scientific purposes after you have died.
19. Autopsy – this is the medical examination of your body after death to
determine the cause of death.

ADVANCE HEALTH CARE DIRECTIVE OF:
________________________________________
(name)
ATTENTION HEALTH CARE PROVIDERS:
This document is an Advance Health Care Directive – a legally binding document

under state and federal law, which dictates the health care treatment that may be
given to an individual who lacks capacity to make health care decisions. Cal.
Probate Code Section 4600 et seq.; 42 Code of Federal Regulations Sections
431.20, 489.100, 489.102, and 489.104.
This Advance Health Care Directive contains a Power of Attorney for Health Care
and/or Individual Health Care Instructions. If no agent is designated under the
Power of Attorney for Health Care section of this document, or if the agent cannot
be located, health care providers must still follow any Individual Health Care
Instructions contained in this document. Cal. Probate Code Sections 4670, 4671.
An agent has priority over any other person in making health care decisions for the
patients. Cal. Probate Code Section 4685.
SPECIFIC DUTIES OF HEALTH CARE PROVIDERS INCLUDE:
Maintaining this document in the patient's health records. Cal. Probate Code
Section 4731(a).
Notifying the designated agent that the patient lacks or has recovered capacity.
Cal. Probate Code Section 4732.
Providing the designated agent access to the patient’s health records. Cal.
Probate Code Section 4678.
DURATION AND REVOCABILITY:
Advance Health Care Directives do not expire unless a specific expiration date is
stated in the document. Cal. Probate Code Section 4686.
ADVANCE HEALTH CARE DIRECTIVE Page 1 of 28

A patient having capacity may revoke the designation of an agent by a signed
writing or by personally informing the health care provider, and may revoke any
and all other parts of an Advance Health Care Directive in any manner that
communicates an intent to revoke. Cal. Probate Code Section 4695.
Be aware that an agent is not authorized to make a health care decision if the
patient objects to the decision. Before implementing a health care decision made
for a patient, the health care provider must promptly inform the patient about the
decision and the identity of the person making the decision. Cal. Probate Code
Sections 4689, 4730.
In addition, this document states that no individual mental or physical health care
instruction may be carried out against the wishes of the patient. If the patient
objects to his or her agent’s health care decision or to the implementation of an
individual mental or physical health care instruction contained in this document,
the matter concerning that particular procedure shall be governed by the law that
would apply if there were no Power of Attorney for Health Care or Individual
Health Care Instruction regarding that procedure. Cal. Probate Code Section 4689.
LIABILITY AND IMMUNITY:
Failure to follow an Advance Health Care Directive may result in liability for
damages specified in California law or actual damages, whichever is greater, plus
attorney’s fees. Cal. Probate Code Section 4742. Violators may also be liable for
negligence, malpractice and battery claims.
Health care providers are not subject to civil or criminal liability or to discipline
for unprofessional conduct for compliance with Advance Health Care Directives.
Cal. Probate Code Section 4740.
DISCRIMINATION PROHIBITED:
Health care providers and health care insurers may not require or prohibit the
execution or revocation of an Advance Health Care Directive as a condition for
providing health care, admission to a facility, or furnishing insurance. Cal. Probate
Code Section 4677.

ADVANCE 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 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 I of this form is a power of attorney for health care. Part I 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 through 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 co-worker.)
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 II(a) of this form lets you give specific instructions about any aspect of your
mental health care, whether or not you appoint an agent. Choices are provided for
you to express your wishes regarding the provision of mental health care, and at
the end of Part II(a), space is provided for you to add any additional choices about
mental health care which are not covered elsewhere.
Part II(b) of this form lets you give specific instructions about any aspect of your
physical health care, including end-of-life decisions and instructions about
anatomical gifts, autopsy, and disposition of your remains.
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.
If you or your agent have difficulty enforcing this advance health care directive,
contact your county patient's rights advocate or Protection and Advocacy, Inc.
(1-800-776-5746).

Advance Health Care Directive of _____________________________________
(Your name)
Instructions Included in My Directive
Put a check mark in the left-hand column for each section you have completed.
# PART I
Appointment of an Agent for Healthcare
1 Designation of Health Care Agent
Designation of Alternate Health Care Agent
2 Authority Granted to My Agent
3 My choice as to a Court Appointed Conservator
# PART II(a)
Statement of Individual Mental Health Care Instructions
4 Who, In Addition to My Health Care Agent, Should Be Notified
Immediately of My Admission To a Psychiatric Facility?
5 My Choice of Treatment Facility and Choices for Alternatives to
Hospitalization If 24-Hour Care is Deemed Medically Necessary for My
Safety and Well-being
6 My Primary Physician who is to Have Primary Responsibility for my
Mental Health Care is:
7 My Choices about primary Physicians Who Will Treat Me if I Am
Hospitalized and my Primary Physician is Unavailable
8 My Choices Regarding Methods for Avoiding Emergency Situations
9 My Choices Regarding Emergency Interventions
9(a) My Choices Regarding Routine Medications for Psychiatric Treatment
9(b) My Choices Regarding Emergency Psychiatric Medication
10 My Choices Regarding Electroconvulsive Therapy
11 The Following People Are to be Prohibited from Visiting Me
12 Other Instructions About Mental Health Care

# PART II(b)
Individual Physical Health Care Instructions
13 My Primary Physician who is to Have Primary Responsibility for my
Physical Health Care is:
14 Statement of Desires, Special Provisions and Limitations
15 My Choices Regarding Experimental Studies and Drug Trials
16 My Instructions Regarding Life Sustaining Treatment
17 My Choices Regarding Contribution of Anatomical Gift
18 My Instructions Regarding Autopsy
19 Choices Regarding Disposition of My Remains

(Your name)
PART I
APPOINTMENT OF AN AGENT FOR HEALTH CARE
**MAKE SURE YOU GIVE YOUR AGENT

A COPY OF ALL SECTIONS OF THIS DOCUMENT**
If no agent is designated under the Power of Attorney for Health Care section of
this document, or if the agent cannot be located, health care providers must still
follow any Individual Health Care Instructions contained in this document. Cal.
Probate Code Sections 4670, 4671. An agent has priority over any other person in
making health care decisions for the patients. Cal. Probate Code Section 4685.
STATEMENT OF INTENT TO APPOINT AN AGENT:
I, (your name) , being of sound mind,

authorize a health care agent to make certain decisions of my behalf regarding my
health treatment when I am incompetent to do so unless I mark this box , in
which case my agent's authority to make health care decisions for me takes effect
immediately. I intend that those decisions should be made in accordance with my
expressed wishes as set forth in this document. If I have not expressed a choice in
this document, I authorize my agent to make the decision that my agent determines
is the decision I would make if I were competent to do so.

1. Designation of Health Care Agent
A. I hereby designate and appoint the following person as my agent to make
health care decisions for me as authorized in this document. This person is to
be notified immediately of my admission to a psychiatric facility.
Name: ____________________________________________________________
Address: __________________________________________________________
City, State, Zip Code: ________________________________________________
Day Phone: _______________________ Evening Phone: __________________
Pager: ___________________________ Cell Phone: ______________________
Designation of Alternate Health Care Agent

If the person named above is unavailable, unable or unwilling to serve as my agent,
I hereby appoint and desire immediate notification of my alternative agent as
follows:
Name: ____________________________________________________________
Address: __________________________________________________________
Pager: ___________________________ Cell Phone: ______________________

2. Authority Granted to My Agent
If I become incapable of giving informed consent to health care treatment, or if I

marked the box under "Statement of Intent to Appoint an Agent" causing my
agent's authority to make decisions for me to immediately become effective, I
hereby grant to my agent full power and authority to make health care decisions for
me, including the right to consent, refuse consent, or withdraw consent to any
health care, treatment, service or procedure, consistent with any instructions and/or
limitations I have set forth in this advance directive EXCEPT as I state here. If I
have not expressed a choice in this advance directive, I authorize my agent to make
the decision that my agent determines is the decision I would make if I were
competent to do so.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
3. My Choice as to a Court-Appointed Conservator

In the event a court decides to appoint a conservator who will make decisions
regarding my health treatment, I desire the following person to be appointed:
Name: ___________________________ Relationship:_____________________
Address: __________________________________________________________
Pager: ___________________________ Cell Phone: ______________________
The appointment of a conservator or other decision maker shall not give the
conservator or decision maker the power to revoke, suspend, or terminate my
individual health care instructions or the powers of my agent.
**MAKE SURE YOU GIVE YOUR AGENT AND ALTERNATE AGENT

A COPY OF ALL SECTIONS OF THIS DOCUMENT**

(Your name)
PART II(a)
STATEMENT OF INDIVIDUAL
MENTAL HEALTH CARE INSTRUCTIONS
In this part, you state how you wish to be treated (such as which hospital you wish
to be taken to, which medications you prefer) if you become incapacitated or
unable to express your own wishes. If you want a paragraph to apply, put your
initials before the paragraph letter. If you do not want the paragraph to apply to
you, leave the line blank.
NO INDIVIDUAL MENTAL OR PHYSICAL HEALTH CARE INSTRUC-

TION CONTAINED IN THIS DOCUMENT MAY BE CARRIED OUT
AGAINST MY WISHES.

4. Who, In Addition to My Health Care Agent, Should Be Notified
Immediately of My Admission To a Psychiatric Facility? Be sure to include the
agent and any alternate agent you designate in your Durable Power of Attorney, if
you have one.
Name: ____________________________________________________________
Address: __________________________________________________________
Pager: ___________________________ Cell Phone: ______________________
Name: ____________________________________________________________
Address: __________________________________________________________
Pager: ___________________________ Cell Phone: ______________________
Name: ____________________________________________________________
Address: __________________________________________________________
Pager: ___________________________ Cell Phone: ______________________
Name: ____________________________________________________________
Address: __________________________________________________________
Pager: ___________________________ Cell Phone: ______________________

5. My Choice of Treatment Facility and Choices for Alternatives to
Hospitalization If 24-Hour Care is Deemed Medically Necessary for My
Safety and Well-being
____ A. In the event my psychiatric condition is serious enough to require 24-
hour care and I have no physical conditions that require immediate access
to emergency medical care, I would prefer to receive this care at the
following programs/facilities instead of psychiatric hospitalization.
Facility’s Name: ___________________________________________________
Reason: __________________________________________________________
Facility’s Name: ____________________________________________________
Reason: __________________________________________________________
Facility’s Name: ___________________________________________________
Reason: __________________________________________________________
____ B. In the event I am to be admitted to a hospital for 24-hour care, I would
prefer to receive care at the following hospitals:
Facility’s Name: ___________________________________________________
Reason: __________________________________________________________
Facility’s Name: ____________________________________________________
Reason: __________________________________________________________
Facility’s Name: ___________________________________________________
Reason: __________________________________________________________
____ C. I do not wish to be admitted to the following hospitals or
programs/facilities for psychiatric care for the reasons I have listed:
Facility’s Name: ___________________________________________________
Reason: __________________________________________________________
Facility’s Name: ____________________________________________________
Reason: __________________________________________________________
Facility’s Name: ___________________________________________________
Reason: __________________________________________________________

6. My Primary Physician who is to Have Primary Responsibility for my
Mental Health Care is:
Dr. ____________________________ Phone __________________________
Address ________________________ Pager __________________________
City, State, Zip ___________________ _________________________________
7. My Choices about the Physicians Who Will Treat Me if I Am Hospitalized

and my Primary Physician is Unavailable
Put your initials before the letter and complete if you wish either or both
paragraphs to apply.
____ A. My choice of treating physician if the above physician is unavailable is:
Dr._____________________________ Phone __________________________
Address ___________________________________________________________
OR if neither is available
Dr._____________________________ Phone __________________________
OR if none of the above is available
Dr._____________________________ Phone __________________________
____ B. I do not wish to be treated by the following, for the reasons stated:
Dr._____________________________ Reason: _________________________
OR _______________________________
Dr._____________________________ Reason: _________________________
OR _______________________________
Dr._____________________________ Reason: _________________________
_______________________________

8. My Choices Regarding Methods for Avoiding Emergency Situations
If during my admission or commitment to a mental health treatment facility it is

determined that I am engaging in behavior that may make emergency intervention
necessary, I prefer the following choices to help me regain control:
Fill in numbers, giving 1 to your first choice, 2 to your second, and so on until
each has a number. If your choice is not listed, write it in after “other” and give it
a number as well.
Provide a quiet private place

Have a staff member of my choice talk with me one-on-one
Allow me to engage in physical exercise
Offer me recreational activities
Assist me with telephoning a friend or family member
Offer me the opportunity to take a warm bath
Offer me medication
Offer me a cigarette
Allow me to go outside
Provide me with materials to journal or do artwork
Offer me assistance with breathing or calming exercises
Provide me with a radio to listen to
Other: __________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

9. My Choices Regarding Emergency Interventions
If, during an admission or commitment to a mental health treatment facility, it is
determined that I am engaging in behavior that requires an emergency intervention
(e.g., seclusion and/or physical restraint and/or medication), my wishes regarding
which form of emergency interventions should be made as follows. I prefer these
interventions in the following order:
Fill in numbers, giving 1 to your first choice, 2 to your second, and so on until
each has a number. If an intervention you prefer is not listed, write it in after
“other” and give it a number as well. If you do not want a listed intervention ever
used, cross it out and explain why under "Reasons for my choices."
Reasons for my choices

Seclusion _______________________________
Physical restraints _______________________________
Seclusion and physical restraint _______________________________
(combined) _______________________________
Medication by injection _______________________________
Medication in pill form _______________________________
Liquid medication _______________________________
During seclusion and/or restraint, I _______________________________
prefer to be checked by female staff
_______________________________
During seclusion and/or restraint, I
prefer to be checked by male staff _______________________________
Other:________________________ _______________________________
_____________________________ _______________________________
See Section 9(b) for choices regarding _______________________________

emergency medication
I expect the choice of medication in an emergency situation to reflect any choices I
have expressed in this section and in Section 9(b). The choices I express in this
section and Section 9(b) regarding medication in emergency situations do not
constitute consent to use of the medication for non-emergency treatment.

9(a). My Choice Regarding Routine Medications for Psychiatric Treatment
In this section, you may choose any of the paragraphs A-G that you wish to apply.
Be sure to initial those you choose.
If it is determined that I am not legally competent to consent to or to refuse

medications relating to my mental health treatment, my wishes are as follows:
____ A. I consent to the medications agreed to by my agent, after consultation

with my treating physician and any other individuals my agent may think
appropriate, with the reservations, if any, described in (D) below.
____ B. I consent to and authorize my agent to consent to the administration of:

Medication Name Not to exceed the OR In such dosage(s) as
or Medication Type following dosage/day determined by
___________________ ___________________ Dr. _______________
___________________ ___________________
___________________ ___________________ Or if unavailable,
then by
___________________ ___________________
___________________ ___________________ Dr. _______________
___________________ ___________________
___________________ ___________________
___________________ ___________________
____ C. I consent to the medications deemed appropriate by Dr. _____________ ,

whose address and phone number are: ___________________________
__________________________________________________________

9(a) Continued
____ D. I specifically do not consent and I do not authorize my agent to consent

to the administration of the following medications or their respective brand name,
trade name, or generic equivalents:
Name of Drug Reason for Refusal
_________________________ ______________________________________
______________________________________
_________________________ ______________________________________
______________________________________
_________________________ ______________________________________
______________________________________
_________________________ ______________________________________
______________________________________
____ E. I am willing to take the medications excluded in (D) above if my only
reason for excluding them is their side effects and the dosage can be
adjusted to eliminate those side effects.
____ F. I am concerned about the side effects of medications and do not consent
or authorize my agent to consent to any medication that has any of the
side effects I have checked below at 1% or greater level of incidence
(check all that apply).
Tardive dyskinesia Tremors

Loss of Sensation Nausea/vomiting
Motor Restlessness Neuroleptic Malignant Syndrome
Seizures Other ________________________
_____________________________
Muscle/skeletal rigidity
_____________________________
____ G. I have the following other choices about psychiatric medications:

_________________________________________________________________
_________________________________________________________________

9(b) My Choices Regarding Emergency Psychiatric Medication
If during my admission or commitment to a mental health facility, it is determined

that I am engaging in behavior that requires emergency psychiatric medication, I
prefer the following medication:
Medication Name Not to exceed the OR In such dosage(s) as

or Medication Type following dosage/day determined by
___________________ ___________________ Dr. _______________
___________________ ___________________
___________________ ___________________ Or if unavailable,
then by
___________________ ___________________
___________________ ___________________ Dr. _______________
___________________ ___________________
___________________ ___________________
___________________ ___________________
The choices expressed in this section regarding medication in emergency

situations do not constitute consent to use of the medication for non-
emergency treatment.
10. My Choices Regarding Electroconvulsive Therapy
____ A. I do not consent to administration of electroconvulsive therapy.
B. Under California law, this Directive cannot be used to consent for

electroconvulsive therapy. However, if I am administered electroconvulsive
therapy, I have the following choices:
I will be administered no more than the following number of treatments _____ .

I will be administered the number of treatments deemed appropriate by
Dr. _________________________, whose phone number and address is:
_____________________________________________________________.

11. The Following People Are to be Prohibited from Visiting Me:
Name Relationship
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
_______________________________ _______________________________
12. Other Instructions About Mental Health Care

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
(You may attach additional pages if you need more space to complete your
statement. If you attach additional pages, you must sign and date EACH of the
additional pages at the same time you sign and date this document.)

(Your name)
PART II(b)
INDIVIDUAL PHYSICAL HEALTH CARE INSTRUCTIONS
NO INDIVIDUAL MENTAL OR PHYSICAL HEALTH CARE INSTRUC-

TION CONTAINED IN THIS DOCUMENT MAY BE CARRIED OUT
AGAINST MY WISHES
13. My Primary Physician who is to have primary responsibility for my

physical health care is:
Dr._____________________________ Phone __________________________

Address ________________________ Pager___________________________
OR if the above physician is unavailable, then I request:
Dr._____________________________ Phone __________________________
Address: __________________________________________________________
OR if neither of the above is available, then I request:
Dr._____________________________ Phone __________________________
Address: __________________________________________________________
I specifically do not want to be treated by the following physicians:
Dr._____________________________ Reason: _________________________
OR _______________________________
Dr._____________________________ Reason: _________________________
OR _______________________________
Dr._____________________________ Reason: _________________________
_______________________________

14. Statement of Desires, Special Provisions and Limitations
____ A. I specifically express the following desires concerning these health care
decisions:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
____ B. And I specifically limit this Advance Directive as follows:

_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
(You may attach additional pages if you need more space to complete your
statement. If you attach additional pages, you must sign and date EACH of the
additional pages at the same time you sign and date this document.)

15. My Choices Regarding Experimental Studies and Drug Trials
I will not participate in experimental studies or drug trials.
Under recent changes to California law, a health care agent, if one has been
appointed, a conservator, a family member, or domestic partner may consent to
participation in a medical experiment on behalf of a person who is unable to
consent under very specific circumstances. See Health and Safety Code, section
24178 for a list of these specific circumstances.
Complete this section only if you do not consent to participation in medical

experiments under any circumstances.

16. My Instructions Regarding Life Sustaining Treatment
____ A. I do not want my life to be prolonged and I do not want life-sustaining

treatment to be provided or continued: (1) if I am in an irreversible coma or
persistent vegetative state; or (2) if I am terminally ill and the application of life
sustaining procedures would serve only to artificially delay the moment of my
death; or (3) under any other circumstances where the burdens of treatment
outweigh the expected benefits. I want the relief of suffering and the quality as
well as the possible extension of my life considered in making decisions
concerning life-sustaining treatment.
OR
____ B. I want my life to be prolonged and I want life sustaining treatment to be

provided unless I am in a coma or vegetative state which my doctor reasonably
believes to be irreversible. Once my doctor has reasonably concluded that I will
remain unconscious for the rest of my life, I do not want life-sustaining treatment
to be provided or continued.
OR
____ C. I want my life to be prolonged to the greatest extent possible without

regard to my condition, the chances I have for recovery or the cost of procedures.
AND/OR
____ D. I specifically express the following desires concerning life-sustaining

treatment.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

17. My Choices Regarding Contribution of Anatomical Gift
If either statement reflects your desires, sign the line next to the statement. You do
not have to sign either statement. If you do not wish to sign either statement, your
agent (if you have one) and your family will have the authority to make a gift of all
or part of your body under the Uniform Anatomical Gift Act.
I do want to make a gift under the

Uniform Anatomical Gift Act,
effective upon my death, of:
Any needed organs or parts; or _______________________________
The parts or organs listed: (Signature)
_____________________________
_____________________________
_____________________________
I do not want to make a gift under
the Uniform Anatomical Gift Act, _______________________________
nor do I want my agent or family to (Signature)
do so.
18. My Instructions Regarding Autopsy
If either statement reflects your desires, sign the line next to the statement. You do
not have to sign either statement. If you do not sign either statement, your agent (if
you have one) and your family will be able to authorize an autopsy.
I do authorize an examination of my _______________________________

body after death to determine the (Signature)
cause of my death.
I do not authorize an examination of _______________________________
my body after death to determine the (Signature)
cause of my death.

19. Choices Regarding Disposition of my Remains
If either statement reflects your desires, sign the line beneath the statement. You do
not have to sign either statement. If you do not sign either statement, your agent (if
you have one) and your family will be able to direct the disposition of your
remains.
I do authorize
_______________________________ ________________________________
(name) (phone)
_________________________________________________________________
(address/city/state/zip)
to direct the disposition of my remains by the following method:
Burial
Cremation
_______________________________________________________
(signature)
OR
I have described the way I want my remains disposed of in:
A written contract for funeral services with:
_____________________________________________________________
(name and phone of mortuary/cemetery)
_____________________________________________________________
(address/city/state/zip)
My will.
Other:____________________________
_______________________________________________________
(signature)

By signing below, I am executing this advance directive for health care and,
by so doing, am revoking any prior durable power of attorney for health care.
EFFECT OF COPY: A copy of this form has the same effect as the original.
SIGNATURE: Sign and date the form here in the presence of your
witnesses/notary.
_______________________________ _______________________________
(date) (signature)
_______________________________ _______________________________
(address) (print your name)
_______________________________
(city) (state)

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) (print name)
________________________________ ________________________________
(address) (address)
________________________________ ________________________________
(city) (state) (city) (state)
________________________________ ________________________________
(signature of witness) (signature of witness)
________________________________ ________________________________
(date) (date)
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)

SPECIAL WITNESS REQUIREMENT: 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) (signature)
_______________________________ _______________________________
(address) (print your name)
_______________________________
(city) (state)

ACKNOWLEDGEMENT OF NOTARY PUBLIC
State of California)
County of _______________________ )
On ___________________, before me, ________________________(here insert

name and title of the officer), personally appeared __________________________
personally known to me (or proved to me on the basis of satisfactory evidence) to
be the person whose name is subscribed to the within instrument and
acknowledged to me that he/she executed the same.
WITNESS my hand and official seal.
Signature: ________________________________________ (Seal)
This document is valid only if signed by two witnesses OR acknowledged

before a notary public.

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5088.

Protection & Advocacy, Inc.

In California, an Advance Directive is made of up two parts, (1)

2. What is a Healthcare Agent?

It is not necessary to name a Healthcare Agent in order to complete an

General Information Page 1 of 6

4. What can an Advance Directive do for a person with a

An Advance Directive can empower the person to make her

General Information Page 2 of 6

6. How does an Advance Directive become official?

A statement of the person’s intent to create an Advance Directive.

7. When does an Advance Directive go into effect?

The Advance Directive is no longer in effect as soon as the person regains

8. Who can help with filling out an Advance Directive?

General Information Page 3 of 6

9. Is a Healthcare Agent necessary?

However, there are good reasons to name a Healthcare Agent. A

10. What happens when a person wants to change an Individual

To change an Individual Healthcare Instruction, the person must

be at least 18 years old,

General Information Page 4 of 6

11. Who should have a copy of the Advance Directive?

Each of the person’s healthcare providers should have a copy of the

12. Does a healthcare provider have to follow an Advance Directive?

General Information Page 5 of 6

General Information Page 6 of 6

The listing of specific codes at the end of paragraphs is included so that

Some important legal terms in this section are:

1. Capacity – in this document, “capacity” refers to your ability to

2. Duration – in California there is no automatic time limit on an

4. Liability – in California health care providers can be sued for

5. Immunity – In California health care providers who are following an

Explanation of Terms Page 1 of 4

PART I: APPOINTMENT OF AN AGENT FOR HEALTH CARE

8. Conservator – this is someone whom the court may appoint to

PART II(a): STATEMENT OF INDIVIDUAL MENTAL HEALTH CARE

9. Incapacity – this is another way of saying that you “lack capacity.” It

Explanation of Terms Page 2 of 4

a. Seclusion – a method of control that removes you and isolates you by

b. Restraint – a method of control that physically limits your ability to

b. Motor Restlessness – being unable to stop yourself from moving as a

c. Muscle/Skeletal Rigidity – extreme stiffness that is a side effect of

d. Neuroleptic Malignant Syndrome – the name given to a group of

14. Electroconvulsive Therapy – sometimes called ECT or “shock

PART II(b): INDIVIDUAL PHYSICAL HEALTH CARE INSTRUCTIONS

Explanation of Terms Page 3 of 4

Explanation of Terms Page 4 of 4

ATTENTION HEALTH CARE PROVIDERS:

This document is an Advance Health Care Directive – a legally binding document

SPECIFIC DUTIES OF HEALTH CARE PROVIDERS INCLUDE:

DURATION AND REVOCABILITY:

ADVANCE HEALTH CARE DIRECTIVE Page 1 of 28

LIABILITY AND IMMUNITY:

ADVANCE HEALTH CARE DIRECTIVE Page 2 of 28

(a) Consent or refuse consent to any care, treatment, service, or procedure to

(b) Select or discharge health care providers and institutions.

(c) Approve or disapprove diagnostic tests, surgical procedures, and programs

(d) Direct the provision, withholding, or withdrawal of artificial nutrition and

ADVANCE HEALTH CARE DIRECTIVE Page 3 of 28

Day Phone: _____ Evening Phone:

Pager: _____ Cell Phone:

Day Phone: _____ Evening Phone:

Pager: _____ Cell Phone:

Day Phone: _____ Evening Phone:

Pager: _____ Cell Phone:

Day Phone: _____ Evening Phone:

Pager: _____ Cell Phone:

Day Phone: _____ Evening Phone:

Pager: _____ Cell Phone:

Day Phone: _____ Evening Phone:

Pager: _____ Cell Phone:

Dr. __ Phone

Address Pager __

City, State, Zip _ _______________

Provide a quiet private place

C. I consent to the medications deemed appropriate by Dr. _________ ,

Tardive dyskinesia Tremors

I will be administered no more than the following number of treatments _____ .

Dr.___ Phone