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TAKING CHARGE OF YOUR HEALTH CARE
You must be a competent adult at the time of executing the document.
You must name an agent to serve when you become incompetent (there are restrictions on who can be the agent).
The document must be witnessed by two individuals (there are important restrictions on who . can be witnesses) or notarized by a notary public.
If the document is a printed form document which you purchase, it must contain certain statutory warnings.
There are several places to obtain a printed form DPAHC that you
can use. First, under the requirements of a federal law that took
effect December 1991, hospitals must notify you of your right to sign
an advance medical directive and . provide you with a form. Second,
your personal physician may have such forms. And, third, you can
purchase forms from most stationery stores or from the California
Medical Association; located in San Francisco, California.
BE SURE TO FOLLOW ALL THE INSTRUCTIONS OF THE FORM WHEN
EXECUTING THE DOCUMENT.
Natural Death Act Declaration
The Natural Death Act Declaration (NDAD) is a document that allows
you to tell your physician that you want to withhold or withdraw
life-sustaining treatment in the event of a terminal illness where
such treatment will t1) merely prolong the process of dying, and (2)
is not necessary for your comfort or relief of pain. (Prior to 1992,
California had a different version of the Natural Death Act that was
known as the "Directive to Physicians"). A valid NDAD requires the
following:
You must be a competent adult.
The form and wording of the document must substantially comply with the law.
It must be signed by you.
It must be witnessed by two individuals (there are important restrictions on who can be a witness).
The NDAD becomes effective when the following conditions exist
1. you have given a copy of the NDAD to your physician;
2. you are diagnosed and certified in writing as being in a terminal or permanent unconscious condition; and
3. you are no longer competent to make your own medical decisions.
DPAHC or NDAD?
You are probably asking yourself whether you should execute a
DPAHC or a NDAD: Both. documents are valuable tools, but the DPAHC
has several advantages over the NDAD. Most importantly:
Competency
In order for your advance medical directive to be valid, you must be
competent at the time you sign it. In other words, you must be of
sound mind and have a clear understanding of your actions at the time
you signed thedocument.
The following steps may be useful to help establish competency:
Preparing the Document
A lawyer is not needed to prepare either of these advance medical
directives, and printed forms are available for your use.
However, if you are a person with AIDS or are HIV positive and you
want assistance executing these documents, contact the AIDS legal
service in your area.
The program will arrange for a volunteer attorney to assist you in
drafting either a Durable Power of Attorney for Health Care or a
Natural Death Act Declaration. There is no charge for those who meet
financial eligibility quidelines. If you are unable to make an office
visit, a panel attorney will come to your home or hospital room.
To assist the attorney in drafting the document regarding your
medical decisions, please review this pamphlet and take the time to
educate yourself about what type of information you want in the
document. If you have a particular question, write it down and be
sure to ask the attorney. The attorney will be happy to answer any
questions which you have.
Optional Items to Include in Your DPAHC
In addition to the information contained on the printed form DPAHC,
you can include various other statements pertaining to your medical
care which are of concern to you.
(Note: This is a sample of desires, special provisions, and
limitations to the California Medical Association's form for the
Durable Power of Attomey for Health Care ("DPA/HC"). The statement is
illustrative, not exhaustive, of the powers recognized by Cal. Civ.C.
2410-2443, and the statement is to be used in conjunction with the
printed form.)
I, (Your Name), of (City, State), do hereby nominate,
constitute and appoint (Name of Agent), of (City, State), as my true
and lawful attorney-in-fact, to act for me in my name, place and
stead, with regard to any and all medical and health care decisions
to be made concerning my medical condition, treatment and care,
including, but not limited to the following powers:
A. Priority in Visitation. To be given first priority in
visitation should I be a patient in any hospital, health care
facility, or institution including, but not limited to, any ,
intensive care or coronary units of any medical facility, and should
I be unable to express a preference on account of my illness or
disability.
B. Employment of Health Care Personnel. To employ such
physicians, dentists, nurses, therapists, and other professional or
non-professionals, as my attorney-in-fact may deem necessary or
appropriate for my physical or mental well-being; and to pay from my
funds reasonable compensation for all services performed by such
persons.
C. Gain Access to Medical and Other Personal Information. To
request, review, and receive any information, verbal or written,
regarding my personal affairs or my physical or mental health,
including medical and hospital records, and to execute any releases
or other documents that may be required in order to obtain this
information.
D. Receive Items of Personal Property and Effects. To receive
into (his/her) possession any and all items of personal property and
effects which may be recovered from, on, or about my person by any
hospital; police agency or any other person at the time of my
illness, disability or death.
E. Consent or Refuse Consent to Medical Care. To give or
withhold consent to medical care, surgery, or any other medical
procedures or tests; to arrange for my hospitalization, convalescent
care or home care'; and to revoke, withdraw, modify or change consent
to such medical care, surgery, or any other medical procedures or
test, hospitalization, convalescent care or homecare which I or my
attorney-in-fact may have previously allowed or consented to.
I ask my attorney-in-fact to be guided in making such decisions by
what I have told my attorney- in-fact about my personal preferences
regarding such care.
Based on those same preferences, my attorney-in-fact may also summon
paramedics or other emergency medical personnel and seek emergency
treatment for me, or choose not to do so, as my attorney-in-fact
deems appropriate given my wishes and my medical status at the time
of the decision. My attorney-in-fact is authorized, when dealing with
hospitals and physicians, to sign documents entitled or purporting to
be "Refusal to Permit Treatment" and "Leaving Hospital Against
Medical Advice" as well as any necessary waivers of or releases from
liability required by the hospitals orphysicians to implement my
wishes regarding medical treatment or non-treatment.
F. Refuse Life-Prolonging Treatment or Procedures. To request
that aggressive medical therapy not be instituted or be discontinued,
including (but not limited to) cardiopulmonary resuscitation, the
implantation of a cardiac pacemaker, renal dialysis, parenteral
feeding, the use of respirators or ventilators, nasogastric tube use,
endotracheal tube use, and organ transplants. My attorney-in-fact
should try to discuss the specifics of any such decision with me if I
am able to communicate in any manner.
If I am unconscious, comatose, senile, or otherwise unreachable by
such communication, my attorney-in-fact should make the decision
guided by any preferences which I may have previously expressed and
the information given by the physicians treating me as to my medical
diagnosis and prognosis. My attorney-in-fact may specifically request
and concur in the writing of a "no-code" (do not resuscitate) order
by the attending or treating physician.
G. Provide Relief From Pain. To consent to and arrange for the
administration of pain-relieving drugs of any type, or other surgical
or medical procedures calculated to relieve any pain even though
their use may lead to permanent physical damage, addiction, or even
hasten the moment of (but not intentionally cause) my death.
My attorney-in-fact may also consent to and arrange for
unconventional pain-relief therapies such as biofeedback, guided
imagery relaxation therapy, acupuncture, skin stimulation or
cutaneous stimulation, and other therapies which I or my
attorney-in-fact believe may be helpful to me.
H. Protect My Right of Privacy. To exercise my right. of
privacy to make decisions regarding. my medical treatment and my
right to be left alone-even though the exercise of my right may
hasten death or be against. conventional medical advice.
My attorney-in-fact may take appropriate legal action, if necessary
in the judgment of my attorney-in-fact, to enforce my rights in this
regard.
I. Authorize Release of My Body. To authorize there lease of
my body from any hospital or any other authority having possession of
my body at the time of my death and to make all decisions necessary
for the removal and transportation of my body from the place of
death.
J. (OPTIONAL) Authorize Cremation of My Body and - Disposition of
My Remains. To authorize the cremation of my body and to receive
my ashes, whereupon my attorney-in-fact is to place (QUANTITY) in an
urn, and place this - urn with its contents in an appropriate site at
(LOCATION), which I hereby select as my final resting place
It is my hope and desire that (NAME OF PARTNER) will arrange that
(his/her) body will be cremated after (his/her) death, and will be
placed in an urn next to my own ashes in the same site as (LOCATION),
and that we will share a plaque bearing our names and dates of birth
and death. My attorney-in-fact may, as (he/she) chooses, dispose of,
keep, or distribute any of my ashes which (he/she) does not inter at
(LOCATION).
If it is impossible or highly impracticable for my attorney-in-fact
to perform any of the instructions I have given regarding my
cremation or interment, my attorney-in-fact may, at (his/her)
discretion, dispose of my body in such a manner as (he/she) deems
appropriate under the circumstances.
K. (OPTIONAL) Authorize Funeral or Memorial Service. I
authorize my attorney-in-fact to make such arrangements for a funeral
or memorial service in the (NAME OF RELIGIOUS AFFILIATION OR
TRADITION) as are not inconsistent with the wishes I have
expressed above regarding my interment.
L. Execute Documents and Contracts. To sign, execute,
acknowledge, and make declaration in any document(s) that may be
necessary or proper in order to exercise any of the powers described
In this document, to enter into contracts and to pay reasonable
compensation or costs in the exercise of any such powers.
This Durable Power of Attorney shall take effect upon my incapacity.
Said incapacity shall be defined as my failure, due to deteriorating
physical or mental health, to be able to make informed decisions
regarding the' course of my medical treatment, or my failure, due to
deteriorating physical or mental health, to be able to sign any
documents or perform any act necessary to make decisions regarding
that course of my medical treatment.