Advance Directives

Advance Health Care Directive (English and Spanish)

More like this: Advance Directives | English | Planning | Spanish

The Advance Health Care Directive is a legally binding form that lets you exercise your right to give instructions about your own health care and/or to name someone else to make health care decisions for you in the event you are unable to speak for yourself. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. In any case, agents designated and signatures required must be done in the manner prescribed on this form and mandated by the California State Legislature.

It is recommended that you use this form and complete the whole form. Completing this form will revoke any previous health care directives. It is advisable to also complete the Values Checklist we provide and include that as an attachment to your Advance Directive to help clarify your wishes.

Equally important is having meaningful conversations with people who care about you so that they know and understand your wishes concerning end of life care. Guidelines to help Talking Things Over are provided on this site to help you through the process.

Upon completion of your Advance Healthcare Directive, copies should be distributed to family members and those who would care for you in the event of a life-threatening condition. It is also recommended that you keep a current copy of your Advance Directive in the glove box of your vehicle.

PDF format

Download Advance Healthcare Directive in PDF format. (You need the free Acrobat Reader to open and print this file.)

DOC format

Download Advance Healthcare Directive in DOC format. (You must have Microsoft Word or a compatible program to open and print this file.)

en Espanol

Download Advance Healthcare Directive in Spanish

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End of Life Values-Choices Checklist

More like this: Advance Directives | English | Planning | Spanish

English

The End of Life Values-Choices Checklist is a form that lets you think about end of life choices and values, and commit them to writing.

If you prefer, you can download the End of Life Values-Choices Checklist in Microsoft Word (.doc) format.

Spanish

The End of Life Values-Choices Checklist is a form that lets you think about end of life choices and values, and commit them to writing.

If you prefer, you can download the End of Life Values-Choices Checklist in Microsoft Word (.doc) format.

» read more | 5555 reads

Go Wish Cards, Elizabeth S. Menkin, MD

More like this: Advance Directives | Talking Things Over

Go Wish cards order information, Frequently Asked Questions and examples of clinical uses of these Values Sorting Cards helpful when considering end of life choices are provided at this site. The Go Wish cards were created by Elizabeth Menkin, MD and the CODA Alliance to simplify advance care planning choices and assist with setting goals of care.

» 1959 reads | visit Go Wish Cards, Elizabeth S. Menkin, MD

Medic Alert Bracelet

More like this: Advance Directives | Caregiving | Planning

MedicAlert® is the leading personal health record repository for medical information with its famous Medic Alert bracelet and medical id alert necklaces recognized worldwide. Medic Alert bracelets and necklaces are used to inform emergency responders about medications, do not resuscitate orders and other information important if you are unable to speak for yourself.

» 604 reads | visit Medic Alert Bracelet

Physician Orders for Life-Sustaining Treatment (POLST)

More like this: Advance Directives | Legislative, Regulatory, Finance | Models & Research | Talking Things Over

Physician Orders for Life-Sustaining Treatment (POLST) is a document to help ensure that a patient’s wishes are known and honored toward the end of life. It uses a standardized medical order used to indicate which types of life-sustaining treatment a seriously ill patient wants or doesn’t want if his or her condition worsens.

POLST assists health care providers and patients or their surrogate to develop a transferable care plan of desired interventions when dealing with serious, life-limiting illness. Through focused conversations about preferences for nature and intensity of care, people are able to establish a customized standard of care across care settings. The bright pink card stock form travels with the patient and is legally binding in California when properly dated and signed.

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Prehospital Do Not Resuscitate Form & Information

More like this: Advance Directives | Bills, Laws, Regulations | Planning

This form was developed by the CA Emergency Medical Services Authority, in concert with the CA Medical Association and emergency medical services (EMS) providers, for purposes of instructing EMS personnel to forego resuscitation attempts in the event of a patient's cardiopulmonary arrest. This form orders that no medical procedure be done to restart breathing or heart functioning if the heart stops beating or a person stops breathing. This form does not prevent a person from obtaining other emergency medical care and may be revoked at any time. This is a physician order that must be signed by your physician and is legally binding. The DNR form, guidelines and Frequently Asked Questions may be accessed via the link provided.

Thinking Ahead: My Way, My Choice, My Life at the End

This advance care planning workbook was designed by and for people with developmental disabilities to enable them to do their own advance care planning. A DVD video is also available and may be previewed online. This project was created by the California Coalition for Compassionate Care, the Board Resource Center and Mark Starford who has extensive experience and expertise in adapting complex information for persons with developmental disabilities. This is also a great resource to use when working with the frail elderly, people with low reading comprehension or anytime simplification of complex advance health care planning issues would be helpful. It is also available in Spanish and Chinese.