Home > Empowerment Documents: How to Write Advance Health Care Directives, POLSTs, and Power of Attorney Using Free Statutory Forms on the Internet

Empowerment Documents:

How to Prepare Advance Health Care Directives, POLSTs, and Powers of Attorney Using Free California Statutory Forms Available on the Internet

Introduction

This guide will help you write three documents that are legally valid in California, using free statutory forms available on the internet. The first two documents cover health care, while the power of attorney form covers everything else. All three documents express your wishes and/or empower someone to act on your behalf when you are unconscious, unable to communicate, or lack legal capacity to make your own decisions.

The links below were all working as of September, 2017, when this document was written. If you find that a link no longer works, please contact us and we will correct this publication and also send you a link that does work. You can reach this publication’s author at michele {at} TanyaProject {dot} org.

Please note that these documents may not be legally valid if you are not a California resident.

Please be sure to read the entire guide, because unless you know what to do with these documents after you’ve signed them, they won’t do you any good.

Also, this guide does not present information on how to answer every question on each form, so make sure to read each question carefully, and be sure you understand it before you try to answer it.

If you don’t have access to a computer and printer, most public libraries now have both available for anyone to use. Typically it’s free to use the computers, and there’s a small charge for printing.

Advance Health Care Directive

Why Bother: You can use an Advance Health Care Directive to express your wishes about what kind of health care you want if you are unconscious or unable to communicate. You can also use it to list the name of one or more people you empower to make health care decisions on your behalf, when you are unable to do so.

Having this document lets your loved ones, your caregivers, and your health care team know what to do when you cannot tell them. It is important not just to make sure you receive the care you want, but also to let your loved ones know what you want, so they can advocate in unison rather than fight among themselves. When one family member wants care another wants to avoid, it can lead to needless pain and acrimony that can be avoided if your wishes are clearly spelled out in this document.

An Advance Health Care Directive also specifies what you want done with your body after your death, and whether you want to be an organ donor.

STEP #1: Download the California Advance Health Care Directive statutory form here: (note that the document is 8 pages long and appears in this link first in English, and then in Spanish):

http://www.calhospital.org/sites/main/files/file-attachments/consentforms_3.pdf 

STEP #2:  Choose Your Advocates:  Identify the people you want to empower to act on your behalf if you are unable to express your wishes. Please make sure the people you pick understand what their responsibility will be, and that they are comfortable taking it on. Be sure to share your wishes with that person, and make sure she or he is willing to carry them out regardless of their own beliefs, or what they might want for their own end-of-life care.

It’s wise to pick an agent who is local, so they can advocate at your bedside. It’s also wise to name more than one agent, in case your first choice is out of the country or otherwise unavailable.

You’ll need to list each agent’s contact information on your form, especially their cell phone number.

STEP #3:  List your Health Care Providers, Your Preferred Hospital, & Medications You Can’t Take:

  1. Make sure your two health care forms include the name and contact information of your treating physician, as well as the hospital you prefer using. Of course, you should make sure your doctor has treating privileges in the hospital of your choice.
  2. It is also wise to list medications to which you are allergic in your Advance Health Care Directive. You can add that information on the bottom of Page 4 under “Other Wishes.”

STEP #4:  Express Your Wishes: These are not easy choices, so take the time to talk with people you trust, your children, and the people you live with about your wishes.

You’ll find that it takes time and reflection to fill out an Advance Health Care Directive, and it’s important to let your caregivers know your wishes, or at least the name and contact information of the health care agent you list in your Advance Health Care Directive.

STEP #5:  Copy Your Health Care Documents Onto Hot Pink Paper: Ideally your Advance Health Care Directive and POLST (Physician Orders for Life-Sustaining Treatment) forms should be printed on hot pink paper, so they stand out, and emergency health care workers can find them easily. Health care professionals are trained to look for hot-pink colored documents when a patient is unable to communicate and no family member is present.

STEP #6: Make Your Advance Health Care Directive Legally Binding under California Law:  The California Advance Health Care Directive statutory form can be finalized either with a notary (who must watch you sign your document), or by using two adult witnesses—neither of which can be the agent you named in your document. Also, one of the two witnesses cannot be related to you or inherit anything under your will. If you reside in a skilled nursing facility, you will need to add one additional signature of a person designated under California law as a patient advocate or ombudsperson.

STEP #7: Distribute: Give a copy of your Advance Health Care Directive to your health care providers, and make sure they file them with your medical records. Also make sure your document is scanned so it becomes part of your electronic medical records. Don’t forget to include a copy for the hospital that is closest to you, and also the hospital where your doctor can treat you. Hospitals require formal agreements with doctors who want to treat their patients on hospital grounds; your doctor will be able to tell you which hospitals she or he can practice in.

Give a copy of your Advance Health Care Directive and POLST to the people you’ve named as your health care agents: both the primary agent, and also backup agents.

Emergency medical workers are trained to look for Advance Health Care Directives and POLSTs on refrigerators, so you might consider taping a copy of your documents there.

STEP #8: Consider Registration: California has an Advance Directive Registry, and if you file your Advance Health Care Directive there it will help your doctors and health care agents find it. For more information about the Advance Directive Registry and how to file your Advance Health Care Directive there, please visit: http://www.sos.ca.gov/registries/advance-health-care-directive-registry/

STEP #9: Update Your Advance Health Care Directive Annually:  Once a year, check in with your health care agents to make sure they are still willing to take on that responsibility, and that they understand your wishes and know where their copy of your Advance Health Care Directive and POLST are so they can find them easily in an emergency. Then make sure their contact information remains up to date on your Advance Health Care Directive, so your agent(s) can be found quickly in an emergency.

POLST: Physician Orders for Life-Sustaining Treatment

Why Bother: The POLST is a simple two-page form that is signed by you and your doctor.  Emergency Medical Technicians will follow it more readily than an Advance Health Care Directive—simply because they are trained to follow doctor’s orders. So although all you need under California law is an Advance Health Care Directive, pragmatically speaking, it’s smart to have a POLST as well. You don’t want to argue with ambulance personnel during an emergency—you simply want them to follow the wishes expressed in your document.

It is easy to fill out a POLST, because it summarizes the information you’ve already written in your Advance Health Care Directive.

Step #1:  Please download the 2016 updated POLST form, available here. You’ll find instructions on how to fill it out on the second page of the form:

http://capolst.org/wp-content/uploads/2015/12/2016_CA_POLST_English.pdf 

STEP #2:  Express Your Wishes:  Fill out Parts A, B, and C on the first page. You can use the instructions on the second page to help you if you’re not sure how to answer a question. You should make sure your wishes are the same as the ones you expressed in your Advance Health Care Directive.

STEP #3:  List your health care agent in Section D on the first page. This should be the same person you named as your agent in your Advance Health Care Directive. Your agent’s signature is not required, only your agent’s name and telephone number is needed.

STEP #4:  List the doctor you trust the most, who knows the most about you, and make sure to include any after-hours contact numbers.

STEP #5: Copy Your Health Care Documents Onto Hot Pink Paper: Just like your Advance Health Care Directive, ideally your POLST form should also be printed on hot pink paper, for exactly the same reason.

STEP #6: Make Your POLST Legally Binding under California Law:  You do not need witnesses or a Notary to complete a POLST.  All that’s required is your signature, and also a signature from your doctor, nurse practitioner, or physician’s assistant in Section D on the first page.  Don’t forget to fill out the top of the second page!

STEP #7: Distribute:  Follow the same distribution instructions as those for Advance Health Care Directives.

Power of Attorney

Why Bother: The Durable Power of Attorney form allows you to appoint someone to protect your rights and ensure your wishes are honored in all aspects of life except health care. You can indicate that you want your agent to have this power as soon as you sign the document, or only if and when you become incapacitated and cannot communicate your wishes. BE CAREFUL. This document empowers the your agent to sell your property and spend your savings, so only name someone you trust completely.

Step # 1:  Please download the California statutory Power of Attorney Form here: http://www.ssrplaw.com/files/ca_stautory_pofa.pdf 

Step # 2:  List the name and address of your agent, right beneath your own name and address. We recommend you name at least one alternate agent in case your first choice is unavailable. Unfortunately, the form does not have room for a second name, so you can write the words “alternate agent listed on page 2, under “Special Instructions,” and then add the name of your alternate agent on page 2, where you indicated you would provide it.

Step # 3:  Indicate the type of power you are giving your agent by initialing the ones you want on the list of powers listed on Page 1. If you want to grant your agent all the powers listed, you only need to initial once, on Line N, which states “ALL OF THE POWERS LISTED ABOVE.”

Step # 4:  Indicate when you want your agent’s power to begin. If you want to empower your agent right away, you don’t need to do anything. However, if you want to empower your agent only if and when you are unable to communicate your own wishes, you must indicate that on the top of the second page, in the area labelled “Special Instructions,” by writing the following words:

“This document becomes effective only upon the occurrence of my incapacity, as conclusively determined by a licensed physician in a written declaration setting forth when my incapacity occurred, dated and signed by said physician under penalty of perjury, and attached to this original form and all copies of this form.  Any person may act in reliance on the physician’s written declaration without liability to the principal or to any other person, regardless of whether or not such incapacity has actually occurred.”

Step # 5:  Make your Power of Attorney Form Legally Enforceable:  You will need a Notary to finalize your Power of Attorney, and to witness your signing your document (so don’t sign it until you are in front of a Notary). Most banks have Notaries on staff, and allow you to call ahead to make an appointment with one. Here’s what to bring with you when you see a Notary:

  1. payment for their services: typically Notaries charge under $20 per signature, and you’ll only need one signature.
  2. in California, Notaries require a picture ID issued by a government agency within the last five years, such as a driver’s license, a passport, or a California State ID, so they can verify your identity.

Please note that the Power of Attorney form should be on white paper—only the two health-related forms we’ve already covered in this guide are printed on hot-pink paper.

Step # 6:  Make sure you give a copy of your Durable Power of Attorney Form to the person(s) you’ve named as your agent, and that they understand they will need to produce a copy to prove you have authorized them to act on your behalf, as well as their own picture ID, to prove they are the person you named in your document.

If your Power of Attorney form authorizes your agent to have control of your finances, you should give a copy of the form to your bank. When you do, ask your bank if they will require you and/or your agent to sign any other forms to authorize your agent to access and use your bank accounts (often banks have their own legal forms they may want you and/or your agent to fill out). 3. It’s wise to check in once a year with your agent to make sure they are still willing to serve in that role, and know where they’ve stored their copy of your Durable Power of Attorney.

Step # 7:  Once a year, contact your agent(s) to make sure they are willing to continue to be your agent, and that they know where their copy of your signed Power of Attorney form is. Make sure to update each agent’s address on your form if they have moved. If you update your agent’s address, make sure to giver your agent a new copy of the form that contains their updated address, so they don’t encounter any problems if they ever need to use your Power of Attorney.

Congratulations!

With these forms, you’ve protected your rights and have expressed your wishes — now you need to make sure your doctors, agents, and loved ones know the forms exist. Remember that you can change your forms at any time — all you have to do is fill out new forms and make sure that everyone who received a copy of your old documents replaces them with your new ones.

###

© 2017 The Tanya Project. Please do not distribute this form without prior written consent, which will be freely given. For permission, please contact Michele Magar at michele {at} tanyaproject {dot} org.