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California Living Will Form (Advance Directive)

The California Advanced Health Care Directive will is provided to give a patient a chance to choose the type of health care and medical treatment they will receive should they become no longer able to  decide due to unconsciousness or coma. The details the principal may include in the Advanced Health Care Directive may describe ending of the principals life.

This document requires attestation by two (2) witnesses or a notary public in accordance with PROB § 4701.

How to Write

Part 1. Power Of Attorney For Health Care

1.1) Designation Of Agents

Enter details of agent and alternative agents.

  • Name
  • Address
  • ZIP code
  • Home telephone number
  • Work telephone number

1.2) Agents Authority

  • Principal must enter details of exceptions to permitted health care.

1.3) When Agents Authority Becomes Effective

  • Check box

1.5) Agents Post Death Authority

  • Principal must enter details of exceptions to post mortem health care decisions.

 

Part 2. Advanced Health Care Directive Form

Instructions For Health Care

2.1) End Of Life Decisions

a) Choice not to prolong life

b) Choice to prolong life

2.2) Relief From Pain

  • Enter exceptions regarding treatment for alleviation of pain.

2.3) Additional wishes

  • Enter instructions regarding any other preferences regarding relief from pain.

 

Part 3. Donations Of Organs At Death

3.1) Upon Death

Check relevant box.

a) To give organs, tissues and body parts.

b) To not give organs, tissues and body parts.

c) To select certain purposes for doantion of body parts

  • (1) Transplant.
  • (2) Therapy.
  • (3) Research.
  • (4) Education.

 

Part 4. Primary Physician (Optional).

4.1) Designation Of Physician

Enter details of Physician and alternative physicians

  • Name.
  • Address.
  • ZIP code.
  • Telephone number.

 

Part 5. 

5.2) Signature

Principal must enter personal details.

  • Print name.
  • Signature.
  • Date.
  • Address.
  • ZIP code.

5.3) Statement Of Witnesses

Witnesses must enter their personal details.

  • Print name.
  • Signature.
  • Date.
  • Address.
  • ZIP code.

 

Part 6. Special Witness Requirements

Statement of Advocate or Ombudsman (Required if patient is in a skilled nursing home).

  • Name
  • Signature
  • Date
  • Address
  • ZIP code