Amended IN Assembly March 22, 2018 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Assembly Bill No. 3211Introduced by Assembly Member KalraFebruary 16, 2018An act to amend Section 71050 of the Public Resources Code, relating to environmental protection. 4701 of the Probate Code, relating to health care decisions.LEGISLATIVE COUNSEL'S DIGESTAB 3211, as amended, Kalra. Environmental data. Advance health care directives.The Health Care Decisions Law, among other things, establishes the requirements for executing a written advance health care directive that is legally sufficient to direct health care decisions. The law provides a form that may be used or modified to create an advance health care directive, and expressly does not require the use of the form.This bill would revise and recast the portion of the form relating to a persons gift of his or her organs, tissues, and parts.Existing law requires the Secretary for Environmental Protection to examine and adopt information technology standards by which public agencies and the regulated community may use computers and other information technology to comply with environmental data reporting requirements, and to establish a standardized electronic format and protocol for the exchange of electronic data for the purpose of meeting the environmental data reporting requirements of specified laws.This bill would make nonsubstantive revisions to legislative findings and declarations relative to the purposes of the above-described law.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NO Local Program: NO Bill TextThe people of the State of California do enact as follows:SECTION 1. Section 4701 of the Probate Code is amended to read:4701. The statutory advance health care directive form is as follows: ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)ExplanationYou 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 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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.(1.4) AGENTS 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) AGENTS 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) ENDOFLIFE 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 LifeI 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 LifeI 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) (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)Education(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.If you want to limit your anatomical gifts in some way, please state your restriction on the following lines: My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.PART 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)(address)(print your name)(city)(state)(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 individuals 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 individuals health care provider, an employee of the individuals 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 witnessSecond witness(print name)(print name)(address)(address)(city)(state)(city)(state)(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 individuals 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 facilitya 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 OMBUDSMANI 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)(address)(print your name)(city)(state)SECTION 1.Section 71050 of the Public Resources Code is amended to read:71050.The Legislature hereby finds and declares all of the following:(a)Environmental data is currently required by, and submitted to, a variety of public agencies with jurisdiction at the state, regional, and local levels of government. The same information is often submitted by the regulated community to different public agencies, almost always on one or more paper forms. Since a different format is now required for each such report, data items are required to be reformatted one or more additional times at a cost of time and money that brings no accompanying environmental benefit.(b)The blizzard of incoming paper reports often exceeds the capacity of a public agency to digest the information. In some cases, the public agency cannot look at or evaluate all of the data received on paper. That problem of data utility is aggravated further by the current wasteful and error-laden practice of retyping data from paper forms into the public agencys computer data base.(c)In many cases, reported data originates in a computer database maintained by the company submitting the report. The retyping of data by the public agency could be completely eliminated if business entities were permitted to submit the data in a single electronic format that every public agency could then use. That standard approach would permit both business entities and public agencies to save time and money that is now spent in reformatting, reentering, and reediting data. The data would also be available more quickly to any member of the public interested in using the data.(d)Business entities already use common, standardized electronic data formats and protocols to exchange commercial and technical information on materials to be transported and used in manufacturing. That application of electronic data interchange is an important factor in determining the competitiveness of business entities in this state. The imposition by government of barriers to, or multiple incompatible data format requirements on, those existing electronic interchanges impairs the competitiveness of business entities without bringing any accompanying environmental benefit.(e)It is the policy of the state, for environmental and hazardous materials reporting purposes, to employ nonproprietary electronic data formats and transmission protocols that already function effectively for ongoing commercial and industrial data exchanges between business entities and across different computer operating systems instead of expending public funds to develop public agency-specific formats and protocols.
Amended IN Assembly March 22, 2018 CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION Assembly Bill No. 3211Introduced by Assembly Member KalraFebruary 16, 2018An act to amend Section 71050 of the Public Resources Code, relating to environmental protection. 4701 of the Probate Code, relating to health care decisions.LEGISLATIVE COUNSEL'S DIGESTAB 3211, as amended, Kalra. Environmental data. Advance health care directives.The Health Care Decisions Law, among other things, establishes the requirements for executing a written advance health care directive that is legally sufficient to direct health care decisions. The law provides a form that may be used or modified to create an advance health care directive, and expressly does not require the use of the form.This bill would revise and recast the portion of the form relating to a persons gift of his or her organs, tissues, and parts.Existing law requires the Secretary for Environmental Protection to examine and adopt information technology standards by which public agencies and the regulated community may use computers and other information technology to comply with environmental data reporting requirements, and to establish a standardized electronic format and protocol for the exchange of electronic data for the purpose of meeting the environmental data reporting requirements of specified laws.This bill would make nonsubstantive revisions to legislative findings and declarations relative to the purposes of the above-described law.Digest Key Vote: MAJORITY Appropriation: NO Fiscal Committee: NO Local Program: NO
Amended IN Assembly March 22, 2018
Amended IN Assembly March 22, 2018
CALIFORNIA LEGISLATURE 20172018 REGULAR SESSION
Assembly Bill No. 3211
Introduced by Assembly Member KalraFebruary 16, 2018
Introduced by Assembly Member Kalra
February 16, 2018
An act to amend Section 71050 of the Public Resources Code, relating to environmental protection. 4701 of the Probate Code, relating to health care decisions.
LEGISLATIVE COUNSEL'S DIGEST
## LEGISLATIVE COUNSEL'S DIGEST
AB 3211, as amended, Kalra. Environmental data. Advance health care directives.
The Health Care Decisions Law, among other things, establishes the requirements for executing a written advance health care directive that is legally sufficient to direct health care decisions. The law provides a form that may be used or modified to create an advance health care directive, and expressly does not require the use of the form.This bill would revise and recast the portion of the form relating to a persons gift of his or her organs, tissues, and parts.Existing law requires the Secretary for Environmental Protection to examine and adopt information technology standards by which public agencies and the regulated community may use computers and other information technology to comply with environmental data reporting requirements, and to establish a standardized electronic format and protocol for the exchange of electronic data for the purpose of meeting the environmental data reporting requirements of specified laws.This bill would make nonsubstantive revisions to legislative findings and declarations relative to the purposes of the above-described law.
The Health Care Decisions Law, among other things, establishes the requirements for executing a written advance health care directive that is legally sufficient to direct health care decisions. The law provides a form that may be used or modified to create an advance health care directive, and expressly does not require the use of the form.
This bill would revise and recast the portion of the form relating to a persons gift of his or her organs, tissues, and parts.
Existing law requires the Secretary for Environmental Protection to examine and adopt information technology standards by which public agencies and the regulated community may use computers and other information technology to comply with environmental data reporting requirements, and to establish a standardized electronic format and protocol for the exchange of electronic data for the purpose of meeting the environmental data reporting requirements of specified laws.
This bill would make nonsubstantive revisions to legislative findings and declarations relative to the purposes of the above-described law.
## Digest Key
## Bill Text
The people of the State of California do enact as follows:SECTION 1. Section 4701 of the Probate Code is amended to read:4701. The statutory advance health care directive form is as follows: ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)ExplanationYou 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 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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.(1.4) AGENTS 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) AGENTS 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) ENDOFLIFE 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 LifeI 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 LifeI 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) (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)Education(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.If you want to limit your anatomical gifts in some way, please state your restriction on the following lines: My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.PART 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)(address)(print your name)(city)(state)(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 individuals 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 individuals health care provider, an employee of the individuals 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 witnessSecond witness(print name)(print name)(address)(address)(city)(state)(city)(state)(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 individuals 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 facilitya 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 OMBUDSMANI 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)(address)(print your name)(city)(state)SECTION 1.Section 71050 of the Public Resources Code is amended to read:71050.The Legislature hereby finds and declares all of the following:(a)Environmental data is currently required by, and submitted to, a variety of public agencies with jurisdiction at the state, regional, and local levels of government. The same information is often submitted by the regulated community to different public agencies, almost always on one or more paper forms. Since a different format is now required for each such report, data items are required to be reformatted one or more additional times at a cost of time and money that brings no accompanying environmental benefit.(b)The blizzard of incoming paper reports often exceeds the capacity of a public agency to digest the information. In some cases, the public agency cannot look at or evaluate all of the data received on paper. That problem of data utility is aggravated further by the current wasteful and error-laden practice of retyping data from paper forms into the public agencys computer data base.(c)In many cases, reported data originates in a computer database maintained by the company submitting the report. The retyping of data by the public agency could be completely eliminated if business entities were permitted to submit the data in a single electronic format that every public agency could then use. That standard approach would permit both business entities and public agencies to save time and money that is now spent in reformatting, reentering, and reediting data. The data would also be available more quickly to any member of the public interested in using the data.(d)Business entities already use common, standardized electronic data formats and protocols to exchange commercial and technical information on materials to be transported and used in manufacturing. That application of electronic data interchange is an important factor in determining the competitiveness of business entities in this state. The imposition by government of barriers to, or multiple incompatible data format requirements on, those existing electronic interchanges impairs the competitiveness of business entities without bringing any accompanying environmental benefit.(e)It is the policy of the state, for environmental and hazardous materials reporting purposes, to employ nonproprietary electronic data formats and transmission protocols that already function effectively for ongoing commercial and industrial data exchanges between business entities and across different computer operating systems instead of expending public funds to develop public agency-specific formats and protocols.
The people of the State of California do enact as follows:
## The people of the State of California do enact as follows:
SECTION 1. Section 4701 of the Probate Code is amended to read:4701. The statutory advance health care directive form is as follows: ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)ExplanationYou 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 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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.(1.4) AGENTS 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) AGENTS 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) ENDOFLIFE 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 LifeI 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 LifeI 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) (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)Education(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.If you want to limit your anatomical gifts in some way, please state your restriction on the following lines: My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.PART 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)(address)(print your name)(city)(state)(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 individuals 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 individuals health care provider, an employee of the individuals 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 witnessSecond witness(print name)(print name)(address)(address)(city)(state)(city)(state)(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 individuals 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 facilitya 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 OMBUDSMANI 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)(address)(print your name)(city)(state)
SECTION 1. Section 4701 of the Probate Code is amended to read:
### SECTION 1.
4701. The statutory advance health care directive form is as follows: ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)ExplanationYou 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 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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.(1.4) AGENTS 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) AGENTS 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) ENDOFLIFE 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 LifeI 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 LifeI 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) (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)Education(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.If you want to limit your anatomical gifts in some way, please state your restriction on the following lines: My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.PART 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)(address)(print your name)(city)(state)(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 individuals 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 individuals health care provider, an employee of the individuals 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 witnessSecond witness(print name)(print name)(address)(address)(city)(state)(city)(state)(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 individuals 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 facilitya 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 OMBUDSMANI 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)(address)(print your name)(city)(state)
4701. The statutory advance health care directive form is as follows: ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)ExplanationYou 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 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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.(1.4) AGENTS 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) AGENTS 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) ENDOFLIFE 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 LifeI 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 LifeI 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) (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)Education(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.If you want to limit your anatomical gifts in some way, please state your restriction on the following lines: My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.PART 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)(address)(print your name)(city)(state)(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 individuals 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 individuals health care provider, an employee of the individuals 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 witnessSecond witness(print name)(print name)(address)(address)(city)(state)(city)(state)(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 individuals 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 facilitya 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 OMBUDSMANI 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)(address)(print your name)(city)(state)
4701. The statutory advance health care directive form is as follows: ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)ExplanationYou 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 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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.(1.4) AGENTS 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) AGENTS 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) ENDOFLIFE 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 LifeI 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 LifeI 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) (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)Education(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.If you want to limit your anatomical gifts in some way, please state your restriction on the following lines: My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.PART 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)(address)(print your name)(city)(state)(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 individuals 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 individuals health care provider, an employee of the individuals 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 witnessSecond witness(print name)(print name)(address)(address)(city)(state)(city)(state)(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 individuals 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 facilitya 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 OMBUDSMANI 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)(address)(print your name)(city)(state)
4701. The statutory advance health care directive form is as follows:
ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)Explanation
# ADVANCE HEALTH CARE DIRECTIVE(California Probate Code Section 4701)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 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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.
(1.4) AGENTS 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) AGENTS 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 CARE
If you fill out this part of the form, you may strike any wording you do not want.
(2.1) ENDOFLIFE 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)
(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)Education
(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.
If you want to limit your anatomical gifts in some way, please state your restriction on the following lines: My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.
PART 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)
(address) (print your name)
(city)(state)
(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 individuals 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 individuals health care provider, an employee of the individuals 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)
(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 individuals 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 facilitya 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)
(address) (print your name)
(city)(state)
* * * * * * * * * * * * * * * *
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 agents 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) AGENTS 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 AGENTS AUTHORITY BECOMES EFFECTIVE: My agents 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 agents authority to make health care decisions for me takes effect immediately.
(1.4) AGENTS 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) AGENTS 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 CARE
If you fill out this part of the form, you may strike any wording you do not want.
(2.1) ENDOFLIFE 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)
(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)Education
(3.1) Upon my death, I give my organs, tissue, and parts for the purposes of transplantation, therapy, research, and education (mark box to indicate yes).
If I checked the box above, I consent to the commencement and maintenance of any temporary medical procedure necessary to evaluate, maintain, or preserve my organs or tissues for purposes of donation, including, but not limited to, administration of medication, mechanical respiration, and artificial nutrition and hydration.
If you want to limit your anatomical gifts in some way, please state your restriction on the following lines:
My choice not to make a gift in this part is not a refusal to make a gift, and my agent, family, or authorized person(s) may make a gift upon my death.
PART 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)
(address)
(print your name)
(city)(state)
(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 individuals 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 individuals health care provider, an employee of the individuals 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)
(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 individuals 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 facilitya 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)
(address)
(print your name)
(city)(state)
The Legislature hereby finds and declares all of the following:
(a)Environmental data is currently required by, and submitted to, a variety of public agencies with jurisdiction at the state, regional, and local levels of government. The same information is often submitted by the regulated community to different public agencies, almost always on one or more paper forms. Since a different format is now required for each such report, data items are required to be reformatted one or more additional times at a cost of time and money that brings no accompanying environmental benefit.
(b)The blizzard of incoming paper reports often exceeds the capacity of a public agency to digest the information. In some cases, the public agency cannot look at or evaluate all of the data received on paper. That problem of data utility is aggravated further by the current wasteful and error-laden practice of retyping data from paper forms into the public agencys computer data base.
(c)In many cases, reported data originates in a computer database maintained by the company submitting the report. The retyping of data by the public agency could be completely eliminated if business entities were permitted to submit the data in a single electronic format that every public agency could then use. That standard approach would permit both business entities and public agencies to save time and money that is now spent in reformatting, reentering, and reediting data. The data would also be available more quickly to any member of the public interested in using the data.
(d)Business entities already use common, standardized electronic data formats and protocols to exchange commercial and technical information on materials to be transported and used in manufacturing. That application of electronic data interchange is an important factor in determining the competitiveness of business entities in this state. The imposition by government of barriers to, or multiple incompatible data format requirements on, those existing electronic interchanges impairs the competitiveness of business entities without bringing any accompanying environmental benefit.
(e)It is the policy of the state, for environmental and hazardous materials reporting purposes, to employ nonproprietary electronic data formats and transmission protocols that already function effectively for ongoing commercial and industrial data exchanges between business entities and across different computer operating systems instead of expending public funds to develop public agency-specific formats and protocols.