California Probate Code Sections 4600-4806 Section 4600. Construction of part Unless the provision or context otherwise requires, the definitions in this article govern the construction of this part. Section 4603. "Community care facility" "Community care facility" means a community care facility as defined in Section 1502 of the Health and Safety Code. Section 4606. "Durable power of attorney for health care" "Durable power of attorney for health care" means a durable power of attorney to the extent that it authorizes an attorney-in-fact to make health care decisions for the principal. Section 4609. "Health care" "Health care" means any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition and includes decisions affecting the principal after death. Section 4612. "Health care decision" "Health care decision" means consent, refusal of consent, or withdrawal of consent to health care, or a decision to begin, continue, increase, limit, discontinue, or not to begin any health care. Section 4615. "Health care provider" "Health care provider" means a person who is licensed, certified, or otherwise authorized or permitted by the law of this state to administer health care in the ordinary course of business or practice of a profession. Section 4618. "Residental care facility for the elderly" "Residential care facility for the elderly" means a residential care facility for the elderly as defined in Section 1569.2 of the Health and Safety Code. Section 4621. "Statutory form durable power of attorney for health care: "Statutory form durable power of attorney for health care" means a durable power of attorney for health care that satisfies the requirements of Chapter 3 (commencing with Section 4770). Section 4650. Compliance with chapter (a) A durable power of attorney executed on or after January 1, 1984, is effective to authorize the attorney-in-fact to make health care decisions for the principal only if the durable power of attorney complies with this chapter. (b) A durable power of attorney executed before January 1, 1984, that specifically authorizes the attorney-in-fact to make decisions relating to the medical or health care of the principal shall be deemed to be valid under this chapter after January 1, 1984, notwithstanding that it fails to comply with subdivision (a) or (c) of Section 4121 or subdivision (a) of Section 4704; but, to the extent that the durable power of attorney authorizes the attorney-in-fact to make health care decisions for the principal, the durable power of attorney is subject to all the provisions of this chapter and to Part 5 (commencing with Section 4900). (c) Nothing in this chapter affects the validity of a decision made under a durable power of attorney before January 1, 1984. Section 4651. Requirements for printed form of durable power of attorney for health care (a) Notwithstanding Section 4703, on and after January 1, 1986, a printed form of a durable power of attorney for health care may be sold or otherwise distributed if it complies with former Section 2433 of the Civil Code as amended by Section 5 of Chapter 312 of the Statutes of 1984, or with former Section 2433 of the Civil Code as in effect at the time of sale or distribution. However, any printed form of a durable power of attorney for health care printed on or after January 1, 1986, that is sold or otherwise distributed in this state for use by a person who does not have the advice of legal counsel shall comply with former Section 2433 of the Civil Code or Section 4703 of this code in effect at the time of printing. (b) Notwithstanding Section 4700, a printed form of a durable power of attorney for health care may be sold or otherwise distributed if it complies with former Section 2432 of the Civil Code as enacted by Section 10 of Chapter 1204 of the Statutes of 1983 or as subsequently amended, or with Section 4700 of this code. However, any printed form of a durable power of attorney for health care printed on or after January 1, 1986, shall comply with the requirements of former Section 2432 of the Civil Code or Section 4700 of this code in effect at the time of printing. (c) A durable power of attorney for health care executed on or after January 1, 1986, is not invalid if it complies with former Section 2432 of the Civil Code as originally enacted or as subsequently amended. A durable power of attorney for health care executed on or after January 1, 1986, using a printed form that complied with former Section 2433 of the Civil Code, as amended by Section 5 of Chapter 312 of the Statutes of 1984, is as valid as if it had been executed using a printed form that complied with former Section 2433 of the Civil Code as thereafter amended or with Section 4703 of this code. Section 4652. Right to make health care decisions on behalf of another (a) Subject to Sections 4720 and 4946, nothing in this part affects any right a person may have to make health care decisions on behalf of another if the attorney-in-fact and any successor attorney-in-fact are unavailable, unwilling, or unable to make health care decisions on behalf of the principal. (b) This part does not affect the law governing health care treatment in an emergency. Section 4653. Validity of instrument executed in another jurisdiction A durable power of attorney for health care or similar instrument executed in another state or jurisdiction in compliance with the laws of that state or jurisdiction or of this state, shall be valid and enforceable in this state to the same extent as a durable power of attorney for health care validly executed in this state. Section 4654. Expiration date; Exception (a) This section applies only to a durable power of attorney for health care that satisfies one of the following requirements: (1) The power of attorney was executed after January 1, 1984, but before January 1, 1992. (2) The power of attorney was executed on or after January 1, 1992, and contains a warning statement that refers to a seven-year limit on its duration. (b) Unless a shorter period is provided in the durable power of attorney for health care, a durable power of attorney for health care described in subdivision (a) expires seven years after the date of its execution unless at the end of the seven-year period the principal lacks the capacity to make health care decisions for himself or herself, in which case the durable power of attorney for health care continues in effect until the time when the principal regains the capacity to make health care decisions for himself or herself. Section 4700. Requirements for attorney-in-fact to make health care decisions An attorney-in-fact under a durable power of attorney may not make health care decisions unless the durable power of attorney satisfies all of the following requirements: (a) The power of attorney specifically grants authority to the attorney-in-fact to make health care decisions. (b) The power of attorney is executed as provided in Section 4121. (c) The power of attorney satisfies the requirements of this article. Section 4701. Requirements of witnesses If the durable power of attorney for health care is signed by witnesses, as provided in Section 4121, in addition to the requirements applicable to witnesses under Section 4122, the following requirements shall be satisfied: (a) None of the following persons may act as a witness: (1) The principal's health care provider or an employee of the principal's health care provider. (2) The operator or an employee of a community care facility. (3) The operator or an employee of a residential care facility for the elderly. (b) Each witness shall make the following declaration in substance: "I declare under penalty of perjury under the laws of California that the person who signed or acknowledged this document is personally known to me to be the principal, or that the identity of the principal was proved to me by convincing evidence, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as attorney-in-fact by this document, and that I am not the principal's health care provider, an employee of the principal's health care provider, the operator of a community care facility, an employee of an operator of a community care facility, the operator of a residential care facility for the elderly, nor an employee of an operator of a residential care facility for the elderly." (c) At least one of the witnesses shall be a person who is not one of the following: (1) A relative of the principal by blood, marriage, or adoption. (2) A person who would be entitled to any portion of the principal's estate upon the principal's death under a will existing at the time of execution of the durable power of attorney for health care or by operation of law then existing. (d) The witness satisfying the requirement of subdivision (c) shall also sign the following declaration in substance: "I further declare under penalty of perjury under the laws of California that I am not related to the principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the principal's estate upon the principal's death under a will now existing or by operation of law." (e) If the principal is a patient in a skilled nursing facility, as defined in subdivision (c) of Section 1250 of the Health and Safety Code, at the time the durable power of attorney for health care is executed, the power of attorney is not effective unless a patient advocate or ombudsman as may be designated by the Department of Aging for this purpose pursuant to any other applicable provision of law signs the instrument as a witness, either as one of two witnesses or in addition to notarization pursuant to subdivision (c) of Section 4121. The patient advocate or ombudsman shall declare that he or she is serving as a witness as required by this subdivision. It is the intent of this subdivision to recognize that some patients in skilled nursing facilities are insulated from a voluntary decisionmaking role, by virtue of the custodial nature of their care, so as to require special assurance that they are capable of willfully and voluntarily executing a durable power of attorney for health care. Section 4702. Persons ineligible to exercise durable power of attorney for health care (a) Except as provided in subdivision (b), the following persons may not exercise authority to make health care decisions under a durable power of attorney: (1) The treating health care provider or an employee of the treating health care provider. (2) An operator or employee of a community care facility. (3) An operator or employee of a residential care facility for the elderly. (b) An employee of the treating health care provider or an employee of an operator of a community care facility or an employee of a residential care facility for the elderly may be designated as the attorney-in-fact to make health care decisions under a durable power of attorney for health care if both of the following requirements are met: (1) The employee is a relative of the principal by blood, marriage, or adoption, or the employee is employed by the same treating health care provider, community care facility, or residential care facility for the elderly that employs the principal. (2) The other requirements of this chapter are satisfied. (c) Except as provided in subdivision (b), if a health care provider becomes the principal's treating health care provider, the health care provider or an employee of the health care provider may not exercise authority to make health care decisions under a durable power of attorney. (d) A conservator may not be designated as the attorney-in-fact to make health care decisions under a durable power of attorney for health care executed by a person who is a conservatee under the Lanterman-Petris-Short Act (Part 1 (commencing with Section 5000) of Division 5 of the Welfare and Institutions Code), unless all of the following are satisfied: (1) The power of attorney is otherwise valid. (2) The conservatee is represented by legal counsel. (3) The lawyer representing the conservatee signs a certificate stating in substance: "I am a lawyer authorized to practice law in the state where this power of attorney was executed, and the principal was my client at the time this power of attorney was executed. I have advised my client concerning his or her rights in connection with this power of attorney and the applicable law and the consequences of signing or not signing this power of attorney, and my client, after being so advised, has executed this power of attorney." Section 4703. Printed form; Contents (a) A printed form of a durable power of attorney for health care that is sold or otherwise distributed in this state for use by a person who does not have the advice of legal counsel shall provide no other authority than the authority to make health care decisions on behalf of the principal and shall contain, in not less than 10--point boldface type or a reasonable equivalent thereof, the following warning statement: WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document, you should know these important facts: This document gives the person you designate as your agent (the attorney--in--fact) the power to make health care decisions for you. Your agent must act consistently with your desires as stated in this document or otherwise made known. Except as you otherwise specify in this document, this document gives your agent the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive. Notwithstanding this document, you have the right to make medical and other health care decisions for yourself so long as you can give informed consent with respect to the particular decision. In addition, no treatment may be given to you over your objection, and health care necessary to keep you alive may not be stopped or withheld if you object at the time. This document gives your agent authority to consent, to refuse to consent, or to withdraw consent to any care, treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. This power is subject to any statement of your desires and any limitations that you include in this document. You may state in this document any types of treatment that you do not desire. In addition, a court can take away the power of your agent to make health care decisions for you if your agent (1) authorizes anything that is illegal, (2) acts contrary to your known desires, or (3) where your desires are not known, does anything that is clearly contrary to your best interests. This power will exist for an indefinite period of time unless you limit its duration in this document. You have the right to revoke the authority of your agent by notifying your agent or your treating doctor, hospital, or other health care provider orally or in writing of the revocation. Your agent has the right to examine your medical records and to consent to their disclosure unless you limit this right in this document. Unless you otherwise specify in this document, this document gives your agent the power after you die to (1) authorize an autopsy, (2) donate your body or parts thereof for transplant or therapeutic or educational or scientific purposes, and (3) direct the disposition of your remains. If there is anything in this document that you do not understand, you should ask a lawyer to explain it to you. (b) The printed form described in subdivision (a) shall also include the following notice: "This power of attorney will not be valid for making health care decisions unless it is either (1) signed by two qualified adult witnesses who are present when you sign or acknowledge your signature or (2) acknowledged before a notary public in California." (c) This section does not apply to the statutory form provided by Section 4771. Section 4704. Requirements for non-printed form of durable power of attorney (a) A durable power of attorney prepared for execution by a person resident in this state that permits the attorney-in- fact to make health care decisions and that is not a printed form shall include one of the following: (1) The substance of the statements provided in subdivision (a) of Section 4703 in capital letters. (2) A certificate signed by the principal's lawyer stating: "I am a lawyer authorized to practice law in the state where this power of attorney was executed, and the principal was my client at the time this power of attorney was executed. I have advised my client concerning his or her rights in connection with this power of attorney and the applicable law and the consequences of signing or not signing this power of attorney, and my client, after being so advised, has executed this power of attorney." (b) If a durable power of attorney includes the certificate provided for in paragraph (2) of subdivision (a) and permits the attorney-in-fact to make health care decisions for the principal, the applicable law of which the client is to be advised by the lawyer signing the certificate includes, but is not limited to, the matters listed in subdivision (a) of Section 4703. Section 4720. Priority of attorney-in-fact over other persons; Exercise of authority to make health care decisions (a) Unless the durable power of attorney provides otherwise, the attorney-in-fact designated in a durable power of attorney for health care who is known to the health care provider to be available and willing to make health care decisions has priority over any other person to act for the principal in all matters of health care decisions, but the attorney-in-fact does not have authority to make a particular health care decision if the principal is able to give informed consent with respect to that decision. (b) Subject to any limitations in the durable power of attorney, the attorney-in-fact designated in a durable power of attorney for health care may make health care decisions for the principal, before or after the death of the principal, to the same extent as the principal could make health care decisions if the principal had the capacity to do so, including the following: (1) Making a disposition under the Uniform Anatomical Gift Act (Chapter 3.5 (commencing with Section 7150) of Part 1 of Division 7 of the Health and Safety Code). (2) Authorizing an autopsy under Section 7113 of the Health and Safety Code. (3) Directing the disposition of remains under Section 7100 of the Health and Safety Code. (c) In exercising the authority under the durable power of attorney for health care, the attorney-in-fact has a duty to act consistent with the desires of the principal as expressed in the durable power of attorney or otherwise made known to the attorney-in-fact at any time or, if the principal's desires are unknown, to act in the best interests of the principal. (d) Nothing in this chapter affects any right the person designated as attorney-in-fact may have, apart from the durable power of attorney for health care, to make or participate in the making of health care decisions on behalf of the principal. Section 4721. Right of attorney-in-fact to receive information, review records, and consent to disclosure of records Except to the extent the right is limited by the durable power of attorney for health care, an attorney-in-fact designated to make health care decisions under a durable power of attorney for health care has the same right as the principal to receive information regarding the proposed health care, to receive and review medical records, and to consent to the disclosure of medical records. Section 4722. Non-authorized health care A power of attorney may not authorize the attorney-in-fact to consent to any of the following on behalf of the principal: (a) Commitment to or placement in a mental health treatment facility. (b) Convulsive treatment (as defined in Section 5325 of the Welfare and Institutions Code). (c) Psychosurgery (as defined in Section 5325 of the Welfare and Institutions Code). (d) Sterilization. (e) Abortion. Section 4723. Unauthorized acts Nothing in this chapter shall be construed to condone, authorize, or approve mercy killing, or to permit any affirmative or deliberate act or omission to end life other than the withholding or withdrawal of health care pursuant to a durable power of attorney for health care so as to permit the natural process of dying. In making health care decisions under a durable power of attorney for health care, an attempted suicide by the principal shall not be construed to indicate a desire of the principal that health care treatment be restricted or inhibited. Section 4724. Effect of objection by principal Nothing in this chapter authorizes an attorney-in-fact to consent to health care, or to consent to the withholding or withdrawal of health care necessary to keep the principal alive, if the principal objects to the health care or to the withholding or withdrawal of the health care. In such a case, the case is governed by the law that would apply if there were no durable power of attorney for health care. Section 4725. Prohibition against requirement that patient execute power of attorney No health care provider, health care service plan, insurer issuing disability insurance, self-insured employee welfare plan, or nonprofit hospital plan or similar insurance plan, may condition admission to a facility, or the providing of treatment, or insurance, on the requirement that a patient execute a durable power of attorney for health care. Section 4726. Conduct causing health care to be withheld or withdrawn in violation of article; Prosecution for unlawful homicide Any person who, except where justified or excused by law, alters or forges a durable power of attorney for health care of another, or willfully conceals or withholds personal knowledge of a revocation as provided under Section 4727, with the intent to cause a withholding or withdrawal of health care necessary to keep the principal alive contrary to the desires of the principal, and thereby, because of that act, directly causes health care necessary to keep the principal alive to be withheld or withdrawn and the death of the principal thereby to be hastened, is subject to prosecution for unlawful homicide as provided in Chapter 1 (commencing with Section 187) of Title 4 of Part 1 of the Penal Code. Section 4727. Revocation of durable power of attorney for health care (a) At any time while the principal has the capacity to give a durable power of attorney for health care, the principal may do any of the following: (1) Revoke the appointment of the attorney-in-fact under the durable power of attorney for health care by notifying the attorney-in-fact orally or in writing. (2) Revoke the authority granted to the attorney-in-fact to make health care decisions by notifying the health care provider orally or in writing. (b) If the principal notifies the health care provider orally or in writing that the authority granted to the attorney-in- fact to make health care decisions is revoked, the health care provider shall make the notification a part of the principal's medical records and shall make a reasonable effort to notify the attorney-in-fact of the revocation. (c) It is presumed that the principal has the capacity to revoke a durable power of attorney for health care. This presumption is a presumption affecting the burden of proof. (d) Unless it provides otherwise, a valid durable power of attorney for health care revokes any prior durable power of attorney for health care. (e) Unless the durable power of attorney for health care expressly provides otherwise, if after executing a durable power of attorney for health care the principal's marriage is dissolved or annulled, the dissolution or annulment revokes any designation of the former spouse as an attorney-in-fact to make health care decisions for the principal. If any designation is revoked solely by this subdivision, it is revived by the principal's remarriage to the former spouse. (f) If authority granted by a durable power of attorney for health care is revoked under this section, a person is not subject to criminal prosecution or civil liability for acting in good faith reliance upon the durable power of attorney for health care unless the person has actual knowledge of the revocation. Section 4750. Limitation on liability of health care provider; Conditions (a) Subject to any limitations stated in the durable power of attorney for health care and to subdivision (b) and to Sections 4722, 4723, 4724, 4725, and 4726, a health care provider is not subject to criminal prosecution, civil liability, or professional disciplinary action except to the same extent as would be the case if the principal, having had the capacity to give informed consent, had made the health care decision on his or her own behalf under like circumstances, if the health care provider relies on a health care decision and both of the following requirements are satisfied: (1) The decision is made by an attorney-in-fact who the health care provider believes in good faith is authorized under this chapter to make the decision. (2) The health care provider believes in good faith that the decision is not inconsistent with the desires of the principal as expressed in the durable power of attorney for health care or otherwise made known to the health care provider, and, if the decision is to withhold or withdraw health care necessary to keep the principal alive, the health care provider has made a good faith effort to determine the desires of the principal to the extent that the principal is able to convey those desires to the health care provider and the results of the effort are made a part of the principal's medical records. (b) Nothing in this chapter authorizes a health care provider to do anything illegal. (c) Notwithstanding the health care decision of the attorney-in-fact designated by a durable power of attorney for health care, the health care provider is not subject to criminal prosecution, civil liability, or professional disciplinary action for failing to withdraw health care necessary to keep the principal alive. Section 4751. "Convincing evidence" For the purposes of the declaration of witnesses required by Section 4701 or 4771, "convincing evidence" means the absence of any information, evidence, or other circumstances which would lead a reasonable person to believe that the person signing or acknowledging the durable power of attorney for health care as principal is not the individual he or she claims to be and any one of the following: (a) Reasonable reliance on the presentation of any one of the following, if the document is current or has been issued within five years: (1) An identification card or driver's license issued by the California Department of Motor Vehicles. (2) A passport issued by the Department of State of the United States. (b) Reasonable reliance on the presentation of any one of the following, if the document is current or has been issued within five years and contains a photograph and description of the person named on it, is signed by the person, bears a serial or other identifying number, and, in the event that the document is a passport, has been stamped by the United States Immigration and Naturalization Service: (1) A passport issued by a foreign government. (2) A driver's license issued by a state other than California or by a Canadian or Mexican public agency authorized to issue drivers' licenses. (3) An identification card issued by a state other than California. (4) An identification card issued by any branch of the armed forces of the United States. (c) If the principal is a patient in a skilled nursing facility, a witness who is a patient advocate or ombudsman may, for the purposes of Section 4701 or 4771, rely upon the representations of the administrators or staff of the skilled nursing facility, or of family members, as convincing evidence of the identity of the principal if the patient advocate or ombudsman believes that the representations provide a reasonable basis for determining the identity of the principal. Section 4752. Presumption of validity In the absence of knowledge to the contrary, a physician and surgeon or other health care provider may presume that a durable power of attorney for health care or similar instrument, whether executed in another state or jurisdiction or in this state, is valid. Section 4753. Liability of health care provider who honors request to forego resuscitative measures (a) A health care provider who honors a request to forego resuscitative measures, as defined in subdivision (b), shall not be subject to criminal prosecution, civil liability, discipline for unprofessional conduct, administrative sanction, or any other sanction, as a result of his or her reliance upon that request, if the health care provider: (1) believes in good faith that the action or decision is consistent with this section, and (2) has no knowledge that the action or decision would be inconsistent with a health care decision that the individual signing the request would have made on his or her own behalf under like circumstances. (b) A "request to forego resuscitative measures" shall be a written document, signed by (1) the individual, or a legally recognized surrogate health care decisionmaker, and (2) a physician and surgeon, that directs a health care provider to forego resuscitative measures. For the purpose of this section, a "request to forego resuscitative measures" shall include a prehospital "do not resuscitate" form as developed by the Emergency Medical Services Authority or other substantially similar form. A request to forego resuscitative measures may also be evidenced by a medallion engraved with the words "do not resuscitate" or the letters "DNR", a patient identification number, and a 24--hour toll--free telephone number, issued by a person pursuant to an agreement with the Emergency Medical Services Authority. (c) Request to forego resuscitative measures forms printed after January 1, 1995, shall contain the following: "By signing this form, the surrogate acknowledges that this request to forego resuscitative measures is consistent with the known desires of, and with the best interest of, the individual who is the subject of the form." (d) A substantially similar printed form shall be valid and enforceable if all of the following conditions are met: (1) It is signed by the individual, or the individual's legally recognized surrogate health care decisionmaker, and a physician and surgeon. (2) It directs health care providers to forego resuscitative measures. (3) It contains all other information required by this section. (e) In the absence of knowledge to the contrary, a health care provider may presume that a request to forego resuscitative measures is valid and unrevoked. (f) This section shall apply whether the individual is within or outside a hospital or other health care facility. (g) For purposes of this section "health care provider" shall include, but not be limited to, those persons described in Section 4615, and emergency response employees, including, but not limited to, firefighters, law enforcement officers, emergency medical technicians I and II, paramedics, or employees or volunteer members of legally organized and recognized volunteer organizations, who are trained in accordance with standards adopted as regulations by the Emergency Medical Services Authority pursuant to Sections 1797.170, 1797.171, 1797.172, 1797.182, and 1797.183 of the Health and Safety Code to respond to medical emergencies in the course of performing their volunteer or employee duties with the organization. (h) This section does not repeal or narrow current laws relating to health care decisionmaking, including the provisions governing the use of the Durable Power of Attorney for Health Care contained in this chapter, and the provisions relating to the use of declarations concerning life sustaining treatments pursuant to the Natural Death Act (Chapter 3.9 (commencing with Section 7185) of Part 1 of Division 7 of the Health and Safety Code). Section 4770. Citation of chapter Section 4771. Form The use of the following form in the creation of a durable power of attorney for health care under Chapter 1 (commencing with Section 4600) is lawful, and when used, the power of attorney shall be construed in accordance with this chapter and is subject to Chapter 1 (commencing with Section 4600), provided, however, that the use of a form previously authorized by this statute (at the time it was so authorized) remains valid. STATUTORY FORM DURABLE POWER OF ATTORNEY FOR HEALTH CARE (California Probate Code Section 4771) WARNING TO PERSON EXECUTING THIS DOCUMENT THIS IS AN IMPORTANT LEGAL DOCUMENT WHICH IS AUTHORIZED BY THE KEENE HEALTH CARE AGENT ACT. BEFORE EXECUTING THIS DOCUMENT, YOU SHOULD KNOW THESE IMPORTANT FACTS: THIS DOCUMENT GIVES THE PERSON YOU DESIGNATE AS YOUR AGENT (THE ATTORNEY-IN-FACT) THE POWER TO MAKE HEALTH CARE DECISIONS FOR YOU. YOUR AGENT MUST ACT CONSISTENTLY WITH YOUR DESIRES AS STATED IN THIS DOCUMENT OR OTHERWISE MADE KNOWN. EXCEPT AS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT GIVES YOUR AGENT THE POWER TO CONSENT TO YOUR DOCTOR NOT GIVING TREATMENT OR STOPPING TREATMENT NECESSARY TO KEEP YOU ALIVE. NOTWITHSTANDING THIS DOCUMENT, YOU HAVE THE RIGHT TO MAKE MEDICAL AND OTHER HEALTH CARE DECISIONS FOR YOURSELF SO LONG AS YOU CAN GIVE INFORMED CONSENT WITH RESPECT TO THE PARTICULAR DECISION. IN ADDITION, NO TREATMENT MAY BE GIVEN TO YOU OVER YOUR OBJECTION AT THE TIME, AND HEALTH CARE NECESSARY TO KEEP YOU ALIVE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT AT THE TIME. THIS DOCUMENT GIVES YOUR AGENT AUTHORITY TO CONSENT, TO REFUSE TO CONSENT, OR TO WITHDRAW CONSENT TO ANY CARE, TREATMENT, SERVICE, OR PROCEDURE TO MAINTAIN, DIAGNOSE, OR TREAT A PHYSICAL OR MENTAL CONDITION. THIS POWER IS SUBJECT TO ANY STATEMENT OF YOUR DESIRES AND ANY LIMITATIONS THAT YOU INCLUDE IN THIS DOCUMENT. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF TREATMENT THAT YOU DO NOT DESIRE. IN ADDITION, A COURT CAN TAKE AWAY THE POWER OF YOUR AGENT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOUR AGENT (1) AUTHORIZES ANYTHING THAT IS ILLEGAL, (2) ACTS CONTRARY TO YOUR KNOWN DESIRES, OR (3) WHERE YOUR DESIRES ARE NOT KNOWN, DOES ANYTHING THAT IS CLEARLY CONTRARY TO YOUR BEST INTERESTS. THE POWERS GIVEN BY THIS DOCUMENT WILL EXIST FOR AN INDEFINITE PERIOD OF TIME UNLESS YOU LIMIT THEIR DURATION IN THIS DOCUMENT. YOU HAVE THE RIGHT TO REVOKE THE AUTHORITY OF YOUR AGENT BY NOTIFYING YOUR AGENT OR YOUR TREATING DOCTOR, HOSPITAL, OR OTHER HEALTH CARE PROVIDER ORALLY OR IN WRITING OF THE REVOCATION. YOUR AGENT HAS THE RIGHT TO EXAMINE YOUR MEDICAL RECORDS AND TO CONSENT TO THEIR DISCLOSURE UNLESS YOU LIMIT THIS RIGHT IN THIS DOCUMENT. UNLESS YOU OTHERWISE SPECIFY IN THIS DOCUMENT, THIS DOCUMENT GIVES YOUR AGENT THE POWER AFTER YOU DIE TO (1) AUTHORIZE AN AUTOPSY, (2) DONATE YOUR BODY OR PARTS THEREOF FOR TRANSPLANT OR THERAPEUTIC OR EDUCATIONAL OR SCIENTIFIC PURPOSES, AND (3) DIRECT THE DISPOSITION OF YOUR REMAINS. THIS DOCUMENT REVOKES ANY PRIOR DURABLE POWER OF ATTORNEY FOR HEALTH CARE. YOU SHOULD CAREFULLY READ AND FOLLOW THE WITNESSING PROCEDURE DESCRIBED AT THE END OF THIS FORM. THIS DOCUMENT WILL NOT BE VALID UNLESS YOU COMPLY WITH THE WITNESSING PROCEDURE. IF THERE IS ANYTHING IN THIS DOCUMENT THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER TO EXPLAIN IT TO YOU. YOUR AGENT MAY NEED THIS DOCUMENT IMMEDIATELY IN CASE OF AN EMERGENCY THAT REQUIRES A DECISION CONCERNING YOUR HEALTH CARE. EITHER KEEP THIS DOCUMENT WHERE IT IS IMMEDIATELY AVAILABLE TO YOUR AGENT AND ALTERNATE AGENTS OR GIVE EACH OF THEM AN EXECUTED COPY OF THIS DOCUMENT. YOU MAY ALSO WANT TO GIVE YOUR DOCTOR AN EXECUTED COPY OF THIS DOCUMENT. DO NOT USE THIS FORM IF YOU ARE A CONSERVATEE UNDER THE LANTERMAN-PETRIS-SHORT ACT AND YOU WANT TO APPOINT YOUR CONSERVATOR AS YOUR AGENT. YOU CAN DO THAT ONLY IF THE APPOINTMENT DOCUMENT INCLUDES A CERTIFICATE OF YOUR ATTORNEY. 1. DESIGNATION OF HEALTH CARE AGENT. I, -------------------------------------------------------------- (Insert your name and address) do hereby designate and appoint --------------------------------- ----------------------------------------------------------------- (Insert name, address, and telephone number of one individual only as your agent to make health care decisions for you. None of the following may be designated as your agent: (1) your treating health care provider, (2) a nonrelative employee of your treating health care provider, (3) an operator of a community care facility, (4) a nonrelative employee of an operator of a community care facility, (5) an operator of a residential care facility for the elderly, or (6) a nonrelative employee of an operator of a residential care facility for the elderly.) as my agent to make health care decisions for me as authorized in this document. For the purposes of this document, "health care decision" means consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure to maintain, diagnose, or treat an individual's physical or mental condition. 2. CREATION OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE. By this document I intend to create a durable power of attorney for health care under Sections 4600 to 4752, inclusive, of the California Probate Code. This power of attorney is authorized by the Keene Health Care Agent Act and shall be construed in accordance with the provisions of Sections 4770 to 4779, inclusive, of the Probate Code. This power of attorney shall not be affected by my subsequent incapacity. 3. GENERAL STATEMENT OF AUTHORITY GRANTED. Subject to any limitations in this document, I hereby grant to my agent full power and authority to make health care decisions for me to the same extent that I could make those decisions for myself if I had the capacity to do so. In exercising this authority, my agent shall make health care decisions that are consistent with my desires as stated in this document or otherwise made known to my agent, including, but not limited to, my desires concerning obtaining or refusing or withdrawing life-prolonging care, treatment, services, and procedures. (If you want to limit the authority of your agent to make health care decisions for you, you can state the limitations in paragraph 4 ("Statement of Desires, Special Provisions, and Limitations") below. You can indicate your desires by including a statement of your desires in the same paragraph.) 4. STATEMENT OF DESIRES, SPECIAL PROVISIONS, AND LIMITATIONS. (Your agent must make health care decisions that are consistent with your known desires. You can, but are not required to, state your desires in the space provided below. You should consider whether you want to include a statement of your desires concerning life-prolonging care, treatment, services, and procedures. You can also include a statement of your desires concerning other matters relating to your health care. You can also make your desires known to your agent by discussing your desires with your agent or by some other means. If there are any types of treatment that you do not want to be used, you should state them in the space below. If you want to limit in any other way the authority given your agent by this document, you should state the limits in the space below. If you do not state any limits, your agent will have broad powers to make health care decisions for you, except to the extent that there are limits provided by law.) In exercising the authority under this durable power of attorney for health care, my agent shall act consistently with my desires as stated below and is subject to the special provisions and limitations stated below: (a) Statement of desires concerning life-prolonging care, treatment, services, and procedures: ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- (b) Additional statement of desires, special provisions, and limitations: ---------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- ----------------------------------------------------------------- (You may attach additional pages if you need more space to complete your statement. If you attach additional pages, you must date and sign EACH of the additional pages at the same time you date and sign this document.) 5. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH. Subject to any limitations in this document, my agent has the power and authority to do all of the following: (a) Request, review, and receive any information, verbal or written, regarding my physical or mental health, including, but not limited to, medical and hospital records. (b) Execute on my behalf any releases or other documents that may be required in order to obtain this information. (c) Consent to the disclosure of this information. (If you want to limit the authority of your agent to receive and disclose information relating to your health, you must state the limitations in paragraph 4 ("Statement of Desires, Special Provisions, and Limitations") above.) 6. SIGNING DOCUMENTS, WAIVERS, AND RELEASES. Where necessary to implement the health care decisions that my agent is authorized by this document to make, my agent has the power and authority to execute on my behalf all of the following: (a) Documents titled or purporting to be a "Refusal to Permit Treatment" and "Leaving Hospital Against Medical Advice." (b) Any necessary waiver or release from liability required by a hospital or physician. 7. AUTOPSY; ANATOMICAL GIFTS; DISPOSITION OF REMAINS. Subject to any limitations in this document, my agent has the power and authority to do all of the following: (a) Authorize an autopsy under Section 7113 of the Health and Safety Code. (b) Make a disposition of a part or parts of my body under the Uniform Anatomical Gift Act (Chapter 3.5 (commencing with Section 7150) of Part 1 of Division 7 of the Health and Safety Code). (c) Direct the disposition of my remains under Section 7100 of the Health and Safety Code. (If you want to limit the authority of your agent to consent to an autopsy, make an anatomical gift, or direct the disposition of your remains, you must state the limitations in paragraph 4 ("Statement of Desires, Special Provisions, and Limitations") above.) 8. DURATION. (Unless you specify otherwise in the space below, this power of attorney will exist for an indefinite period of time.) This durable power of attorney for health care expires on ----- ----------------------------------------------------------------- (Fill in this space ONLY if you want to limit the duration of this power of attorney.) 9. DESIGNATION OF ALTERNATE AGENTS. (You are not required to designate any alternate agents but you may do so. Any alternate agent you designate will be able to make the same health care decisions as the agent you designated in paragraph 1, above, in the event that agent is unable or ineligible to act as your agent. If the agent you designated is your spouse, he or she becomes ineligible to act as your agent if your marriage is dissolved.) If the person designated as my agent in paragraph 1 is not available or becomes ineligible to act as my agent to make a health care decision for me or loses the mental capacity to make health care decisions for me, or if I revoke that person's appointment or authority to act as my agent to make health care decisions for me, then I designate and appoint the following persons to serve as my agent to make health care decisions for me as authorized in this document, these persons to serve in the order listed below: A. First Alternate Agent -------------------------------------- ----------------------------------------------------------------- (Insert name, address, and telephone number of first alternate agent) B. Second Alternate Agent ------------------------------------- ----------------------------------------------------------------- (Insert name, address, and telephone number of second alternate agent) 10. NOMINATION OF CONSERVATOR OF PERSON. (A conservator of the person may be appointed for you if a court decides that one should be appointed. The conservator is responsible for your physical care, which under some circumstances includes making health care decisions for you. You are not required to nominate a conservator but you may do so. The court will appoint the person you nominate unless that would be contrary to your best interests. You may, but are not required to, nominate as your conservator the same person you named in paragraph 1 as your health care agent. You can nominate an individual as your conservator by completing the space below.) If a conservator of the person is to be appointed for me, I nominate the following individual to serve as conservator of the person: ----------------------------------------------------------------- (Insert name and address of person nominated as conservator of the person) 11. PRIOR DESIGNATIONS REVOKED. I revoke any prior durable power of attorney for health care. DATE AND SIGNATURE OF PRINCIPAL (YOU MUST DATE AND SIGN THIS POWER OF ATTORNEY) I sign my name to this Statutory Form Durable Power of Attorney for Health Care on -------- (Date) at ------------------, (City) ------------------ (State). ---------------------- (You sign here) (THIS POWER OF ATTORNEY WILL NOT BE VALID UNLESS IT IS SIGNED BY TWO QUALIFIED WITNESSES WHO ARE PRESENT WHEN YOU SIGN OR ACKNOWLEDGE YOUR SIGNATURE. IF YOU HAVE ATTACHED ANY ADDITIONAL PAGES TO THIS FORM, YOU MUST DATE AND SIGN EACH OF THE ADDITIONAL PAGES AT THE SAME TIME YOU DATE AND SIGN THIS POWER OF ATTORNEY.) STATEMENT OF WITNESSES (This document must be witnessed by two qualified adult witnesses. None of the following may be used as a witness: (1) a person you designate as your agent or alternate agent, (2) a health care provider, (3) an employee of a health care provider, (4) the operator of a community care facility, (5) an employee of an operator of a community care facility, (6) the operator of a residential care facility for the elderly, or (7) an employee of an operator of a residential care facility for the elderly. At least one of the witnesses shall make the additional declaration set out following the place where the witnesses sign.) (READ CAREFULLY BEFORE SIGNING. You can sign as a witness only if you personally know the principal or the identity of the principal is proved to you by convincing evidence.) (To have convincing evidence of the identity of the principal, you must be presented with and reasonably rely on any one or more of the following: (1) An identification card or driver's license issued by the California Department of Motor Vehicles that is current or has been issued within five years. (2) A passport issued by the Department of State of the United States that is current or has been issued within five years. (3) Any of the following documents if the document is current or has been issued within five years and contains a photograph and description of the person named on it, is signed by the person, and bears a serial or other identifying number: (a) A passport issued by a foreign government that has been stamped by the United States Immigration and Naturalization Service. (b) A driver's license issued by a state other than California or by a Canadian or Mexican public agency authorized to issue drivers licenses. (c) An identification card issued by a state other than California. (d) An identification card issued by any branch of the armed forces of the United States. (4) If the principal is a patient in a skilled nursing facility, a witness who is a patient advocate or ombudsman may rely upon the representations of the administrator or staff of the skilled nursing facility, or of family members, as convincing evidence of the identity of the principal if the patient advocate or ombudsman believes that the representations provide a reasonable basis for determining the identity of the principal.) (Other kinds of proof of identity are not allowed.) I declare under penalty of perjury under the laws of California that the person who signed or acknowledged this document is personally known to me (or proved to me on the basis of convincing evidence) to be the principal, that the principal signed or acknowledged this durable power of attorney in my presence, that the principal appears to be of sound mind and under no duress, fraud, or undue influence, that I am not the person appointed as agent by this document, and that I am not a health care provider, an employee of a 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. Signature: Residence Address: Print Name: Date: Signature: Residence Address: Print Name: Date: (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 principal by blood, marriage, or adoption, and, to the best of my knowledge, I am not entitled to any part of the principal's estate upon the principal's death under a will now existing or by operation of law. Signature: ------------------- Signature: ------------------- STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN (If you are a patient in a skilled nursing facility, one of the witnesses must be a patient advocate or ombudsman. The following statement is required only if you are a patient in a skilled nursing facility--a health care facility that provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign both parts of the "Statement of Witnesses" above AND must also sign the following statement.) I further 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 subdivision (e) of Section 4701 of the Probate Code. Signature:------------ Section 4772. Type size of warning statement; Exception; Attorney's certificate (a) Notwithstanding Section 4703, except as provided in subdivision (b), a statutory form durable power of attorney for health care, to be valid, shall contain, in not less than 10-point boldface type or a reasonable equivalent thereof, the warning statement that is set forth in capital letters at the beginning of Section 4771. (b) Subdivision (a) does not apply if the statutory form durable power of attorney for health care contains a certificate signed by the principal's lawyer stating the following: "I am a lawyer authorized to practice law in the state where this power of attorney was executed, and the principal was my client at the time when this power of attorney was executed. I have advised my client concerning his or her rights in connection with this power of attorney and the applicable law and the consequences of signing or not signing this power of attorney, and my client, after being so advised, has executed this power of attorney." Section 4773. Requirements for valid execution (a) Notwithstanding subdivision (c) of Section 4121, a statutory form durable power of attorney for health care is valid, and the designated attorney-in-fact may make health care decisions pursuant to its authority, only if it (1) contains the date of its execution, (2) is signed by the principal, and (3) is signed by two qualified witnesses, each of whom executes, under penalty of perjury, the declaration set forth in the first paragraph of the "Statement of Witnesses" in the form set forth in Section 4771, and one of whom also executes the declaration under penalty of perjury set forth in the second paragraph of the "Statement of Witnesses" in the form set forth in Section 4771. (b) Nothing in this section excuses compliance with the special requirements imposed by subdivision (e) of Section 4701 and subdivision (d) of Section 4702. Section 4774. Power of attorney as valid under chapter; Requirements (a) Subject to subdivisions (b), (c), and (d), a power of attorney is a "statutory form durable power of attorney for health care," as this phrase is used in this chapter, if it meets both of the following requirements: (1) It meets the requirements of Sections 4772 and 4773. (2) It includes the exact wording of the text of paragraphs 1, 2, 3, and 4 of the form set forth in Section 4771. (b) A statutory form durable power of attorney for health care may include one or more or all of paragraphs 5 to 11, inclusive, of the form set forth in Section 4771. (c) A printed statutory form durable power of attorney for health care sold or otherwise distributed in this state for use by a person who does not have the advice of legal counsel shall contain the exact wording of the form set forth in Section 4771, including the warning and instructions, and nothing else. Nothing in this subdivision prohibits selling or otherwise distributing with the printed form (1) material that explains the form and its use if the material is separate from the printed form itself and is not a part of the form executed by the principal or (2) one or more additional pages that are separate from the printed form itself that a person may attach to the printed form as provided in subdivision (d) if the person so chooses. (d) If one or more additional pages are attached to a statutory form durable power of attorney for health care as a statement, or additional statement, to be a part of subparagraph (a) or (b), or both, of paragraph 4 ("Statement of Desires, Special Provisions, and Limitations") of the form set forth in Section 4771, each of the additional pages shall be dated and signed by the principal at the same time the principal dates and signs the statutory form durable power of attorney for health care. Section 4775. Use of form complying with prior law (a) A statutory form durable power of attorney for health care executed on or after January 1, 1992, using a form that complies with former Section 2500 of the Civil Code is as valid as if it had been executed using a form that complies with Section 4771 of this code. (b) Notwithstanding former Section 2501 of the Civil Code or Section 4772 of this code, a statutory form durable power of attorney for health care executed on or after January 1, 1992, is not invalid if it contains the warning using the language set forth in former Section 2500 of the Civil Code instead of the warning using the language set forth in Section 4771 of this code. (c) For the purposes of subdivision (c) of former Section 2503 of the Civil Code and subdivision (c) of Section 4774 of this code, on and after January 1, 1992, a printed statutory form durable power of attorney for health care may be sold or otherwise distributed if it contains the exact wording of the form set forth in former Section 2500 of the Civil Code or the exact wording of the form set forth in Section 4771 of this code, including the warning and instructions, and nothing else; but any printed statutory form durable power of attorney for health care printed on or after January 1, 1992, that is sold or otherwise distributed in this state for use by a person who does not have the advice of legal counsel shall contain the exact wording of the form set forth in former Section 2500 of the Civil Code or the exact wording of the form set forth in Section 4771 of this code, including the warning and instructions, and nothing else. Section 4776. Authority of attorney-in-fact to select and discharge health care professionals In a statutory form durable power of attorney for health care, the language conferring general authority with respect to "health care decisions" authorizes the attorney-in-fact to select and discharge physicians, dentists, nurses, therapists, and other health care professionals as the attorney-in-fact determines necessary to carry out the health care decisions the attorney-in-fact is authorized by the power of attorney to make. Section 4777. Validity of document when executed by attorney-in-fact If a document described in paragraph 5 or 6 of the form set forth in Section 4771 is executed on behalf of the principal by the attorney-in-fact in the exercise of authority granted to the attorney-in-fact by paragraph 5 or 6 of the form set forth in Section 4771, the document has the same effect as if the principal had executed the document at the same time and under the same circumstances and had the capacity to execute the document at that time. Section 4778. Effect of judicial termination of authority; Alternate agents If the authority of the attorney-in-fact under the statutory form durable power of attorney for health care is terminated by the court under Part 5 (commencing with Section 4900), an alternate attorney-in-fact designated in the statutory form durable power of attorney for health care is not authorized to act as the attorney-in-fact unless the court so orders. In the order terminating the authority of the attorney-in-fact to make health care decisions for the principal, the court shall authorize the alternate attorney-in-fact, if any, designated in the statutory form durable power of attorney for health care to act as the attorney-in-fact to make health care decisions for the principal under the durable power of attorney for health care unless the court finds that authorizing that alternate attorney-in-fact to make health care decisions for the principal would not be in the best interests of the principal. Section 4779. Effect of chapter on other provisions Nothing in this chapter affects or limits the use of any other form for a durable power of attorney for health care. Any form complying with the requirements of Chapter 1 (commencing with Section 4600) may be used in lieu of the form provided by Section 4771, and none of the provisions of this chapter apply if the other form is used. Section 4800. Establishment of registry system The Secretary of State shall establish a registry system by which any person who has executed a durable power of attorney for health care may register in a central information center information regarding the durable power of attorney for health care, making that information available upon request to any health care provider, the public guardian, or other person authorized by the registrant. Information that may be received and released is limited to the registrant's name, social security or driver's license or other individual identifying number established by law, if any, address, date and place of birth, the intended place of deposit or safekeeping of the durable power of attorney for health care, and the name and telephone number of the attorney in fact and any alternative attorney in fact. The Secretary of State, at the request of the registrant, may transmit the information he or she receives regarding the durable power of attorney for health care to the registry system of another jurisdiction as identified by the registrant. The Secretary of State may charge a fee to each registrant in an amount such that, when all fees charged to registrants are aggregated, the aggregated fees do not exceed the actual cost of establishing and maintaining the registry. Section 4801. Verification of identities of persons requesting information; Fee not charged for information The Secretary of State shall establish procedures to verify the identities of health care providers, the public guardian, and other authorized persons requesting information pursuant to Section 4800. No fee shall be charged to any health care provider, the public guardian, or other authorized person requesting information pursuant to Section 4800. Section 4802. Information to registrants The Secretary of State shall establish procedures to advise each registrant of the following: (a) A health care provider may not honor a durable power of attorney for health care until it receives a copy from the registrant. (b) Each registrant must notify the registry upon revocation of the durable power of attorney for health care. (c) Each registrant must reregister upon execution of a subsequent durable power of attorney for health care. Section 4804. Effect of failure to register Failure to register with the Secretary of State shall not invalidate any durable power of attorney for health care. Section 4805. Effect of registration on revocation Registration with the Secretary of State shall not affect the ability of the registrant to revoke that durable power of attorney or a later executed power, nor shall registration raise any presumption of validity or superiority among any competing powers or revocations. Section 4806. Construction of chapter Nothing in this chapter shall be construed to require a health care provider to request from the registry information about whether a patient has executed a durable power of attorney for health care. Nothing in this chapter shall be construed to affect the duty of a health care provider to provide information to a patient regarding advance health care directives pursuant to any provision of federal law.