From Noblood

DPA

IMPORTANT

The following is an example of a DPA. It is only intended to serve as a basis for creating one suitable to your needs. In particular, please note specific medical directives and adjust according to your personal wishes. You are responsible to review any DPA with appropriate legal and health care professionals.

Advance Health Care Directive

(California Probate Code §§4600 to 4805)

1. I, <First & Last Name>, fill out this document to set forth my treatment instructions and to appoint a health-care agent in case of my incapacity.
2. I direct that NO TRANSFUSIONS of whole blood, red cells, white cells, platelets, or plasma be given me under any circumstances, even if health-care providers believe that such are necessary to preserve my life. I refuse to predonate and store my blood for later infusion.
3. Regarding minor fractions of blood I ACCEPT ALL minor fractions of blood WITH THE EXCEPTION OF: (a) those that are given as volume expanders; (b) cryoprecitate if re-suspended in plasma; (c) hemoglobin-based oxygen carriers.
4. Regarding medical procedures involving the use of my own blood, except diagnostic procedures, such as blood samples for testing, I ACCEPT ALL medical procedures involving the use of my blood during the course of a surgical procedure WITH THE EXCEPTION OF: (a) when blood leaving my body to be re-infused is not maintained in a closed circuit; (b) plasmapheresis if plasma is used as the replacement fluid.
5. Regarding end-of-life matters I do not want my life to be prolonged if, to a reasonable degree of medical certainty, my situation is hopeless.
6. Regarding other health-care instructions (such as current medicines, allergies, and medical problems): <None or other>
   
7. I give no one (including my agent) any authority to disregard or override my instructions set forth herein. Family members, relatives, or friends may disagree with me, but any such disagreement does not diminish the strength or substance of my refusal of blood or other instructions.
8. Apart from the matters covered above, I appoint the person named below as my agent to make health-care decisions for me. I give my agent full power and authority to consent to or to refuse treatment (including artificial nutrition and hydration) on my behalf, to consult with my doctors and receive copies of my medical records, and to take legal action to ensure that my wishes are honored. If my first appointed agent is unavailable, unable, or unwilling to serve, I appoint an alternate agent below to serve with the same power and authority.
   
   
   

____________________________________________________ Signature

____________________________________________________ Date

<Address>

• STATEMENT OF WITNESSES: I declare under penalty of perjury (1) that the individual who signed or acknowledged this advance health care directive above is personally known to me, or that the individual’s identity was proven to me by convincing evidence, (2) that the individual signed or acknowledged this advance directive in my presence, (3) that the individual appears to be of sound mind and under no duress, fraud, or undue influence, (4) that I am not the person appointed as agent or alternate agent by this advance directive, and (5) that I am not the individual’s health-care provider, an employee of the individual’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.
  
  
  

	____________________________________________________ Signature of witness / Date		____________________________________________________ Signature of witness / Date
	____________________________________________________ Address		____________________________________________________ Address

• ADDITONAL STATEMEMENT OF WITNESS: One of the above witnesses must sign the following declaration: I further declare under penalty of perjury that I am not related to the individual executing this advance health care directive by blood, marriage, or adoption, and to the best of my knowledge, I am not entitled to any part of the individual’s estate upon his or her death under a will now existing or by operation of law.
  
  
  

____________________________________________________ Signature of witness / Date

____________________________________________________ Signature of witness / Date

• SPECIAL WITNESS REQUIREMENT: The statement below is required only if you are a patient in a skilled nursing facility (a health-care facility that provides these basic services: skilled nursing care and supportive car to patients whose primary need is for availability of skilled nursing care on an extended basis). The patient advocate or ombudsman must sign the following statement:
• STATEMENT OF PATIENT ADVOCATE OR OMBUDSMAN

I declare under penalty of perjury that I am a patient advocate or ombudsman as designated by the State Department of Aging and that I am service as a witness as required by Section 4675 of the Probate Code.

____________________________________________________ Signature of patient advocate or ombudsman/ Date

____________________________________________________ Printed name and address

• HEALTH-CARE AGENT: <Name: Address: Telephone(s):>
  
• ALTERNATE HEALTH-CARE AGENT: <Name: Address: Telephone(s):>