PHC Advance Care Planning Packet

4665 Business Center Dr.
Fairfield, CA 94534
PHC Advance Care Planning Packet
This packet contains useful resources to assist clinicians with Advance Care Planning.
Included are the following:
1. Summary of the three phases of Advance Care Planning.
2. PHC’s attestation form, which is required to obtain the financial incentive for doing
Advance Care Planning with your patients with advanced illnesses.
3. A list of websites with useful information, including easy-to-print Advance Directives and
POLST forms in many languages.
4. A FAQ sheet about the POLST form.
5. Samples of the California POLST form in English and Spanish
6. Samples of the Advance Directive form in English and Spanish
We recognize that during a busy clinic schedule, it can be hard to take time to discuss
potential future scenarios for end-of-life care. But making some time for this discussion can
have a big impact on the quality of care for your patients, especially in the event of a
sudden change in their clinical status. One thing that can make the process more efficient is
to always have printed copies of the Advance Directive and POLST forms (in various
languages) readily available in your office. Please consider printing up multiple copies
(available through the websites listed the resources document) for this purpose.
We hope you find this packet helpful. If you have any questions or need more information,
please contact us. To obtain these documents electronically please visit our website.
Jess Lui, Quality Improvement Project Manager, Phone: (707) 863-4543
Marya Choudhry, Quality Improvement Project Manager, Phone: (530)-999-6903
E-Mail: [email protected]
PHC Website: www.partnershiphp.org
4665 Business Center Dr.
Fairfield, CA 94534
The Three Phases of Advance Care Planning:
The Discussion Evolves as a Person Moves Through Life
Phase 1: Initially, an Advance Directive is indicated for any reasonably healthy adult and
may be introduced as young as 18 years old. The purpose is to complete a written Advance
Directive, indicating individual wishes for life sustaining health care, and to select someone
to act as a future proxy health care advocate for health care decisions in the event of a
critical medical situation where the person is unable to communicate their wishes. Ideally,
Advance Directive discussions will be initiated during routine health maintenance visits by
primary care providers.
Phase 2: When a patient has a chronic, long-term disease, multiple co-morbidities,
declining functional living activities, frequent hospitalizations, and high risk complications
from a disease state, the next phase involves more active planning with the individual and
their designated health care advocate. The primary care provider has ongoing discussions
of advance care planning for long-term illnesses and health care decisions.
Phase 3: This phase is for a person with a prognosis of one year or less, very frail elderly
patients, or frail patients living in a long-term care facility. The purpose is to have a
Physician’s Order for Life Sustaining Treatment (POLST) form or an Advance Directive in
place which designates the following: proxy health care advocate, and the patient’s wishes
regarding cardiopulmonary resuscitation, intubation, nutrition and hydration, and comfort
care measures. The purpose of the POLST and Advance Directive is to incorporate the
patient’s wishes into their provider’s medical orders for when a critical or terminal event
occurs.
Appendix IVA: Advance Care Planning – Physician/Clinician Attestation
Discussions by doctors, nurses, physician assistants, and other clinicians about Advance Care Planning
with PHC Medi-Cal or Medi-Medi members ages 65 and older or who have significant health
problems limiting their life expectancy may qualify for a financial bonus under PHC’s Quality
Improvement Program (QIP). You may submit one attestation per member per fiscal year, up to a
maximum of 100 attestations. To be eligible for the incentive, please do the following:
1. Discuss end-of-life choices with your patient
2. Document the ACP discussion in the patient’s medical record
3. Complete this attestation form
ACP discussions must take place between July 1, 2015, and June 30, 2016. All attestations submitted
are reviewed by PHC. Upon approval, the attestation will qualify for the incentive. Attestation forms
should be submitted no later than July 31, 2016 via email at [email protected] or fax at 707-8634316.
------------------------------------------------------------------------------------------------------------------------------Patient Name
Date of Birth
CIN #
Reason for ACP discussion (check one):
65 or older
Under 65, with potential life-limiting illness or concomitant disease process specified below
(Please see Specifications for examples):
I,
(Clinician Name), practicing at
(Organization), hereby attest that
the patient listed above had their choices around advance illness care discussed on
_/
/
(Date of Service). If someone other than me facilitated the conversation about ACP
in our office, that person is trained and competent at conducting these discussions and the conversation
was reviewed and confirmed by me with the patient. This ACP discussion is documented in the Patient’s
medical record, which I agree to being audited by PHC, and includes the following activities:
A. Advance Directive (AD) *One of the three boxes below must be checked for this form to be considered complete
(Click here for AD sample)
Patient completed AD or committed to filling one out after ACP discussion
Patient had previously completed his/her AD and reaffirmed they do not wish to make any changes
Patient declined to complete AD. Information given: pamphlet/handout about Advance Directives
B. POLST *One of the three boxes below must be checked for this form to be considered complete
(Click here for the English California POLST Form)
POLST inappropriate for patient
POLST appropriate and signed
POLST appropriate but declined
Clinician Signature:
Date: _________________________
Appendix IVB: Advance Care Planning – Medical Record Components
The following is a list of components we look for when determining whether an ACP discussion
documented in a medical record qualifies for the ACP incentive:
Basic Information




Patient’s name, date of birth, and CIN
Whether written materials on advance directive and POLST was given to patient to
review, and whether an Advance Directive and/or POLST is completed or updated
Clinician’s name and organization
Date of discussion
Patient general preferences around end of life



At this time, patient wishes all treatments to be done that have any amount of potential
life lengthening effect, regardless of pain or discomfort
At this time, patient would like to balance the potential benefits with the side effects of treatment
options on a case by case basis.
At this time, patient would like only treatments that will alleviate pain, anxiety and
discomfort, even if this shortens life somewhat
If patient is unable to make decisions, and unable to discuss details of care with health care decision
maker, use this course of action:
 All treatments given if my attending physician determines possible benefit.
 Comfort care (includes no tube feeds)
 Comfort care plus a short term trial of tube feed
 All treatments given except
Chest compressions
Cardiac shock
Intubation (breathing tube)
Tube feeds
Intravenous treatments: If heart stops antibiotics
other:
Blood transfusion (List reason:
)
Other specific limitations of care expressed:
Details of discussion: __________________________________________________________
4665 Business Center Dr.
Fairfield, CA 94534
Advance Care Planning and POLST Resources
1. www.iha4health.org - At this site you can easily download and print “Easy-tounderstand” Advance Directive in many languages.
(On the left hand side of the page click on Advance Directive, next select the language.)
2. www.capolst.org - At this site you can easily download and print the POLST form in
many languages.
3. www.coalitionccc.org – At this site you can read about best practices for having Advance
Care planning discussions with families.
4. http://www.aafp.org/afp/1999/0201/p605.html - Article
“Incorporating Advance Care Planning into Family Practice”
Frequently Asked Questions for Providers
What does ‘POLST’ stand for?
POLST stands for Physician Orders for Life-Sustaining Treatment.
What is the POLST form?
POLST is a physician order that helps give seriously ill patients more control over their end-of-life care.
Produced on a distinctive bright pink form and signed by both the doctor and patient, POLST specifies
the types of medical treatment that a patient wishes to receive towards the end of life. As a result, POLST
can prevent unwanted or medically ineffective treatment, reduce patient and family suffering, and help
ensure that patients’ wishes are honored.
What information is included on the POLST form?
The decisions documented on the POLST form include whether to:
• Attempt cardiopulmonary resuscitation,
• Administer antibiotics and IV fluids,
• Use intubation and mechanical ventilation, and
• Provide artificial nutrition.
Why was POLST developed?
POLST was developed in response to seriously ill patients receiving medical treatments that were not
consistent with their wishes. The goal of POLST is to provide a framework for healthcare professionals so
they can provide the treatments patients DO want, and avoid those treatments that they DO NOT want.
Is POLST mandated by law?
Filling out a POLST form is entirely voluntary. However, California law requires that the physician
orders in a POLST be followed by health care professionals, and provides immunity from civil or
criminal liability to those who comply in good faith with a patient’s POLST requests.
Who should have a POLST form?
POLST is designed for seriously ill patients, or those who are medically frail, regardless of their age.
Does the POLST form replace traditional Advance Directives?
The POLST form complements an Advance Directive and is not intended to replace that document. An
Advance Directive is still necessary to appoint a legal health care decisionmaker, and is recommended for
all adults, regardless of their health status.
If someone has a POLST form and an Advance Directive that conflict, which takes precedence?
If there is a conflict between the documents, the more recent document would be followed.
Who should discuss and complete the POLST form with patients?
Having a conversation with a patient about end-of-life issues is an important and necessary part of good
medical care. The law allows anyone who is a health care provider* to assist with the completion of a
POLST form. In many cases, physicians will initiate conversations with their patients to understand their
wishes and goals of care. Depending on the situation and setting, other trained staff members – such as
nurses, social workers, or chaplains – may also play a role in starting the POLST conversation. However,
physicians are responsible for signing the POLST form.
*The term "health care provider" is defined by law as "an individual licensed, certified, or otherwise
authorized or permitted by the law of this state to provide health care in the ordinary course of business or
practice of a profession."
Can a POLST form be completed for patients who can no longer communicate their treatment wishes?
Yes. A health care professional can complete the POLST form based on family members' understanding
of their loved one’s wishes. The appointed decisionmaker can then sign the POLST form on behalf of
their loved one.
What should be done with the form after it is completed and signed?
The original POLST form, on bright pink paper, stays with the patient at all times. If the patient is
transferred to another setting, the POLST form goes with them.
• In the acute care or long-term care setting, the form should be kept in the patient’s medical record
or file.
• At home, patients should be instructed to place the form in a visible location so it can be found easily
by emergency medical personnel – usually on a table near the patient’s bed, or on the refrigerator.
Can a patient’s POLST form be changed?
Yes, the POLST can be modified or revoked by a patient, verbally or in writing, at any time. Changes may
also be made by a physician, or requested by a patient’s decisionmaker, based on new information or
changes in the patient’s condition.
When should a patient’s POLST form be reviewed?
It is good clinical practice to review a patient’s POLST form when any of the following occur:
• The patient is transferred from one medical or residential setting to another;
• There is a significant change in the person’s health status, or there is a new diagnosis;
• The patient’s treatment preferences change.
How can I obtain copies of the POLST form to use with patients/clients?
Health care providers may download the California POLST form at www.caPOLST.org. In order to
maintain continuity throughout California, the form should be copied or printed on 65# Ultra Pink card
stock, available at most office supply stores. POLST forms may be purchased in bulk from MedPass
www.med-pass.com,.
Are faxed copies and/or photocopies valid? Must pink paper be used?
Faxed copies and photocopies are valid. Ultra Pink paper is preferred and used to distinguish the form
from other forms in the patient’s medical record; however, the form will be honored on any color paper.
Is the POLST form available in other languages?
Chinese and Spanish translations of the form are available to assist healthcare providers in explaining the
form. However, the English version of the POLST form must be completed and signed so that emergency
medical personnel and healthcare providers can follow the orders.
Page 2 of 3
Where is POLST being used now?
POLST was originally developed in Oregon. There are a number of states which have established
POLST programs or are currently developing programs. For more information on the national POLST
effort, including published research and a complete listing of states using POLST, visit www.POLST.org.
When was POLST authorized in California?
California State POLST Legislation (AB 3000 (Statutes 2008, Chapter 266)) went into effect on January
1, 2009.
Will a patient’s POLST form be valid when traveling to another state?
The California POLST form is valid in California. If patients are traveling outside California, it is a good
idea for them to take both their Advance Directive and POLST form with them. Both documents, even if
not legally binding, will help health care providers know and honor their wishes.
Which organizations support the use of the POLST form?
California POLST is part of a national effort. For a complete listing of California organizations that
support the use of POLST, click here.
Who is leading the POLST initiative in California?
The Coalition for Compassionate Care of California (CCCC) provides leadership and oversight for
POLST outreach activities in California, with support from the California HealthCare Foundation.
How can I find out more about POLST?
Visit the California POLST website at www.caPOLST.org for additional information and resources.
Page 3 of 3
2011 California POLST Form
Effective April 1, 2011
In order to maintain continuity throughout California, please follow these
instructions:
*** Copy or print POLST form on 65# Cover Ultra Pink card stock. ***
Mohawk BriteHue Ultra Pink card stock is available online and at some
retailers. See below for suggested online vendors.
Ultra Pink paper is used to distinguish the form from other forms in the
patient’s record; however, the form will be honored on any color paper.
Faxed copies and photocopies are also valid POLST forms.
Suggested online vendors for Ultra Pink card stock:
Med‐Pass ‐ www.med‐pass.com
(also carries pre‐printed POLST forms on Ultra Pink card stock)
Boyd’s Imaging Products ‐ www.iboyds.com
Mohawk Paper Store ‐ www.mohawkpaperstore.com
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Physician Orders for Life-Sustaining Treatment (POLST)
EMSA #111 B
(Effective 4/1/2011)
A
Check
One
B
Check
One
First follow these orders, then contact physician. Patient Last Name:
This is a Physician Order Sheet based on the person’s
current medical condition and wishes. Any section not
completed implies full treatment for that section. A Patient First Name:
copy of the signed POLST form is legal and valid.
POLST complements an Advance Directive and is
Patient Middle Name:
not intended to replace that document. Everyone
shall be treated with dignity and respect.
Date Form Prepared:
Patient Date of Birth:
Medical Record #: (optional)
CARDIOPULMONARY RESUSCITATION (CPR):
If person has no pulse and is not breathing.
When NOT in cardiopulmonary arrest, follow orders in Sections B and C.
Attempt Resuscitation/CPR (Selecting CPR in Section A requires selecting Full Treatment in Section B)
Do Not Attempt Resuscitation/DNR (Allow Natural Death)


MEDICAL INTERVENTIONS:
If person has pulse and/or is breathing.
 Comfort Measures Only Relieve pain and suffering through the use of medication by any route,


positioning, wound care and other measures. Use oxygen, suction and manual treatment of airway
obstruction as needed for comfort. Transfer to hospital only if comfort needs cannot be met in current
location.
Limited Additional Interventions In addition to care described in Comfort Measures Only, use
medical treatment, antibiotics, and IV fluids as indicated. Do not intubate. May use non-invasive positive
airway pressure. Generally avoid intensive care.
 Transfer to hospital only if comfort needs cannot be met in current location.
Full Treatment In addition to care described in Comfort Measures Only and Limited Additional
Interventions, use intubation, advanced airway interventions, mechanical ventilation, and defibrillation/
cardioversion as indicated. Transfer to hospital if indicated. Includes intensive care.
Additional Orders:
C
Check
One
D
ARTIFICIALLY ADMINISTERED NUTRITION:
Offer food by mouth if feasible and desired.
 No artificial means of nutrition, including feeding tubes. Additional Orders:
 Trial period of artificial nutrition, including feeding tubes.
 Long-term artificial nutrition, including feeding tubes.
INFORMATION AND SIGNATURES:
Discussed with:
 Patient (Patient Has Capacity)
 Advance Directive dated
 Advance Directive not available
 No Advance Directive
available and reviewed 
 Legally Recognized Decisionmaker
Health Care Agent if named in Advance Directive:
Name:
Phone:
Signature of Physician
My signature below indicates to the best of my knowledge that these orders are consistent with the person’s medical condition and preferences.
Print Physician Name:
Physician Phone Number:
Physician Signature: (required)
Physician License Number:
Date:
Signature of Patient or Legally Recognized Decisionmaker
By signing this form, the legally recognized decisionmaker acknowledges that this request regarding resuscitative measures is consistent with the
known desires of, and with the best interest of, the individual who is the subject of the form.
Print Name:
Relationship: (write self if patient)
Signature: (required)
Address:
Date:
Daytime Phone Number:
Evening Phone Number:
SEND FORM WITH PERSON WHENEVER TRAN SFERRED OR DISC HARGED
HIPAA PERMITS DISCLOSURE OF POLST TO OTHER HEALTH CARE PROVIDERS AS NECESSARY
Patient Information
Name (last, first, middle):
Date of Birth:
Gender:
M
F
Health Care Provider Assisting with Form Preparation
Name:
Title:
Phone Number:
Relationship to Patient:
Phone Number:
Additional Contact
Name:
Directions for Health Care Provider
Completing POLST
• Completing a POLST form is voluntary. California law requires that a POLST form be followed by health care
providers, and provides immunity to those who comply in good faith. In the hospital setting, a patient will be assessed
by a physician who will issue appropriate orders.
• POLST does not replace the Advance Directive. When available, review the Advance Directive and POLST form to
ensure consistency, and update forms appropriately to resolve any conflicts.
• POLST must be completed by a health care provider based on patient preferences and medical indications.
• A legally recognized decisionmaker may include a court-appointed conservator or guardian, agent designated in an
Advance Directive, orally designated surrogate, spouse, registered domestic partner, parent of a minor, closest
available relative, or person whom the patient’s physician believes best knows what is in the patient’s best interest and
will make decisions in accordance with the patient’s expressed wishes and values to the extent known.
• POLST must be signed by a physician and the patient or decisionmaker to be valid. Verbal orders are acceptable with
follow-up signature by physician in accordance with facility/community policy.
• Certain medical conditions or treatments may prohibit a person from residing in a residential care facility for the elderly.
• If a translated form is used with patient or decisionmaker, attach it to the signed English POLST form.
• Use of original form is strongly encouraged. Photocopies and FAXes of signed POLST forms are legal and valid. A
copy should be retained in patient’s medical record, on Ultra Pink paper when possible.
Using POLST
• Any incomplete section of POLST implies full treatment for that section.
Section A:
• If found pulseless and not breathing, no defibrillator (including automated external defibrillators) or chest compressions
should be used on a person who has chosen “Do Not Attempt Resuscitation.”
Section B:
• When comfort cannot be achieved in the current setting, the person, including someone with “Comfort Measures Only,”
should be transferred to a setting able to provide comfort (e.g., treatment of a hip fracture).
• Non-invasive positive airway pressure includes continuous positive airway pressure (CPAP), bi-level positive airway
pressure (BiPAP), and bag valve mask (BVM) assisted respirations.
• IV antibiotics and hydration generally are not “Comfort Measures.”
• Treatment of dehydration prolongs life. If person desires IV fluids, indicate “Limited Interventions” or “Full Treatment.”
• Depending on local EMS protocol, “Additional Orders” written in Section B may not be implemented by EMS personnel.
Reviewing POLST
It is recommended that POLST be reviewed periodically. Review is recommended when:
• The person is transferred from one care setting or care level to another, or
• There is a substantial change in the person’s health status, or
• The person’s treatment preferences change.
Modifying and Voiding POLST
• A patient with capacity can, at any time, request alternative treatment.
• A patient with capacity can, at any time, revoke a POLST by any means that indicates intent to revoke. It is
recommended that revocation be documented by drawing a line through Sections A through D, writing “VOID” in large
letters, and signing and dating this line.
• A legally recognized decisionmaker may request to modify the orders, in collaboration with the physician, based on the
known desires of the individual or, if unknown, the individual’s best interests.
This form is approved by the California Emergency Medical Services Authority in cooperation with the statewide POLST Task Force.
For more information or a copy of the form, visit www.caPOLST.org.
SEND FORM WITH PERSON WHENEVER TRAN SFERRED OR DISC HARGED
Introduction to the
Spanish Translation of POLST Form
POLST is a physician order that gives patients more control over their end-of-life care. Produced
on a distinctive bright pink form and signed by both the physician and patient, POLST specifies
the types of medical treatment that a patient wishes to receive towards the end of life.
This is a Spanish translation of the California POLST form. The translated form is for educational
purposes only to be used when discussing a patient’s wishes documented on the POLST form.
The signed POLST form must be in English so that emergency personnel can read and follow the
orders.
For questions in English, email
about POLST, visit
or call
. To learn more
.
Introducción a la
traducción al español del formulario POLST
POLST es una orden médica que les da a los pacientes más control sobre la atención al final de
su vida. Impresa en un formulario de color rosa brillante distintivo y firmada por el médico y el
paciente, las POLST especifican los tipos de tratamiento médico que el paciente quiere recibir
hacia el final de su vida.
Ésta es una traducción al español del formulario POLST de California. El formulario traducido
solo se debe usar con fines educativos al conversar sobre los deseos del paciente, que se tienen
que documentar en el formulario POLST. El formulario POLST firmado tiene que estar en inglés
para que el personal de emergencia pueda leerlo y seguir las órdenes.
Para preguntas en inglés, envíe un mensaje por correo electrónico a
llame al
. Para obtener más información sobre la orden POLST, visite
.
o
La versión en español solo se debe usar con fines educativos (Spanish version is for educational purposes only).
La ley HIPAA permite la revelación de las POLST a otros profesionales de atención
de la salud en la medida que sea necesario
Órdenes del médico de tratamiento para el mantenimiento de la vida
(Physician Orders for Life-Sustaining Treatment, POLST)
EMSA #111 B
(En vigor 4/1/2011)
A
Marque
uno
B
Marque
uno
Primero siga estas órdenes y después póngase en contacto Apellido del paciente:
con el médico. Esta es una Hoja de órdenes del médico basada
en el estado médico y deseos actuales de la persona. Toda
sección que no esté completada implica tratamiento completo Nombre del paciente:
para esa sección. Una copia del formulario POLST firmado es
legal y válido. Las POLST son un complemento a una directiva
anticipada y no tienen el objetivo de reemplazar ese documento. Segundo nombre del paciente:
Se debe tratar a todos con dignidad y respeto.
Fecha de preparación del
formulario:
Fecha de nacimiento del
paciente:
Nº de registro médico: (opcional)
Resucitación cardiopulmonar (RCP):
Si la persona no tiene pulso y no está respirando.
Cuando NO se halla en paro cardiopulmonar, seguir las órdenes en las secciones B y C.
o Intentar resucitación/RCP (Si selecciona RCP en la sección A tiene que seleccionar Tratamiento completo en la sección B)
o No intentar resucitación/DNR (permitir la muerte natural)
Intervenciones médicas:
Si la persona tiene pulso y/o está respirando.
o Solo medidas paliativas Aliviar el dolor y el sufrimiento por medio del uso de medicación por cualquier vía, posicionamiento,
cuidado de las heridas y otras medidas. Usar oxígeno, succión y tratamiento manual de la obstrucción de las vías respiratorias según
sea necesario para el confort del paciente. Trasladar al hospital solamente si las necesidades paliativas no se pueden cumplir en
la ubicación actual.
o Intervenciones adicionales limitadas Además de la atención descrita en Solo medidas paliativas, usar tratamiento médico,
antibióticos y fluidos intravenosos según esté indicado. No entubar. Se puede usar presión positiva no invasora en las vías
respiratorias. Evitar en general cuidados intensivos.
o Trasladar al hospital solamente si las necesidades paliativas no se pueden cumplir en la ubicación actual.
o Tratamiento completo Además de la atención descrita en Solo medidas paliativas e Intervenciones adicionales limitadas, usar
entubación, intervenciones avanzadas en las vías respiratorias, ventilación mecánica y desfibrilación y cardioversión según esté
indicado. Trasladar al hospital si está indicado. Incluye cuidados intensivos.
Órdenes adicionales:
C
Marque
uno
D
Nutrición administrada artificialmente:
Ofrecer alimentos por boca, si es posible y deseado.
o No administrar nutrición por medios artificiales, incluyendo la alimentación por tubo.
Órdenes adicionales:
o Período de prueba de nutrición artificial, incluyendo la alimentación por tubo.
o Administrar nutrición artificial a largo plazo, incluyendo la alimentación por tubo.
Información y firmas:
Hablado con:
o Paciente (paciente tiene capacidad de hacerlo) o Encargado de tomar decisiones reconocido legalmente
o Directiva anticipada con fecha
, disponible y revisada à
o Directiva anticipada no está disponible
o No hay una directiva anticipada
Agente para la atención de la salud, si fue nombrado en la
directiva anticipada:
Nombre:
Teléfono:
Firma del Médico
Mi firma a continuación indica que a mi mejor saber y entender estas órdenes son consecuentes con el estado médico y las preferencias de la persona.
Nombre del médico en letra de molde:
Firma del médico:
Nº de teléfono del médico:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Nº de licencia profesional del médico:
Fecha:
Firma del paciente o encargado de tomar decisiones reconocido legalmente
Al firmar este formulario, el encargado de tomar decisiones reconocido legalmente reconoce que este pedido relativo a medidas de resucitación es
consecuente con los deseos conocidos y el mejor interés de la persona que es objeto del formulario.
Nombre en letra de molde:
Relación: (escribir Sí mismo si es
el paciente)
Firma: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Fecha:
Dirección:
Nº de teléfono de día:
Nº de teléfono de noche:
Enviar el formulario con la persona si se le trasladada o da de alta
CA POLST Form – Spanish
La ley HIPAA permite la revelación de las POLST a otros profesionales de
atención de la salud en la medida que sea necesario
Información del paciente
Nombre (apellido, nombre, segundo nombre):
Fecha de nacimiento:
Sexo:
M
F
Profesional de atención de la salud que ayuda a preparar el formulario
Nombre:
Título:
Número de teléfono:
Relación con el paciente:
Número de teléfono:
Contacto adicional
Nombre:
Instrucciones para el profesional de atención de la salud
Cómo llenar las POLST
• Llenar un formulario POLST es voluntario. La ley de California requiere que los profesionales de atención de la salud cumplan con lo
•
•
•
•
•
•
•
indicado en las POLST y otorga inmunidad a aquellos que las cumplan de buena fe. En un entorno hospitalario, el paciente será evaluado
por un médico quien emitirá las órdenes apropiadas.
Las POLST no reemplazan una directiva anticipada. Cuando esté disponible, revise la directiva anticipada y el formulario POLST para
verificar que sean consecuentes y actualizar los formularios de manera apropiada para resolver cualquier conflicto.
Las POLST tienen que ser llenadas por un profesional de atención de la salud basándose en las preferencias del paciente y las
indicaciones médicas.
Un encargado de tomar decisiones reconocido legalmente podría incluir a un tutor administrativo o tutor nombrado por la corte, agente
nombrado en una directiva anticipada, sustituto nombrado oralmente, cónyuge, pareja de hecho registrada, uno de los padres de un menor,
pariente más cercano disponible o persona que el médico del paciente considere que conoce mejor lo que está en el mejor interés del
paciente y que tomará decisiones de acuerdo a los deseos y valores expresados por el paciente en la medida que se conozcan.
Para que sean válidas, las POLST tienen que ser firmadas por un médico y por el paciente o encargado de tomar decisiones. Las órdenes
verbales son aceptables con la firma de seguimiento del médico de conformidad con las normas de la instalación/comunidad.
Ciertos problemas médicos o tratamientos podrían impedir que una persona viva en una instalación de cuidados residenciales para
personas mayores.
Si se usa un formulario traducido para un paciente o encargado de tomar decisiones, adjúntelo al formulario POLST en inglés firmado.
Se recomienda enfáticamente el uso del formulario original. Las fotocopias y los facsímiles de los formularios POLST firmados son legales
y válidos. Se debe archivar una copia en el registro médico del paciente, en papel Ultra Pink de ser posible.
Cómo usar las POLST
• Toda sección incompleta de las POLST implica tratamiento completo para esa sección.
Sección A:
• Si se encuentra sin pulso y no está respirando, no se deben usar desfibriladores (incluyendo los desfibriladores automatizados externos) ni
compresiones de pecho en una persona que seleccionó “No intentar resucitación”.
Sección B:
• Cuando no se puede lograr la comodidad del paciente en el lugar actual, la persona, incluyendo a alguien con “Solo medidas paliativas” debe ser
trasladada a un lugar en el que se le puedan proporcionar las medidas paliativas (como por ejemplo, el tratamiento de una fractura de cadera).
• La presión positiva no invasora de las vías respiratorias incluye la presión positiva continua de las vías respiratorias (CPAP), presión
positiva en dos niveles de las vías respiratorias (BiPAP) y respiraciones asistidas por bolsa válvula máscara (BVM).
• Los antibióticos por vía intravenosa y la hidratación en general no se consideran “medidas paliativas”.
• El tratamiento de la deshidratación prolonga la vida. Si una persona desea fluidos intravenosos, indique “Intervenciones limitadas” o
“Tratamiento completo”.
• Dependiendo de las normas de los servicios médicos de emergencia (EMS) locales, es posible que el personal de EMS no implemente las
“Órdenes adicionales” escritas en la sección B.
Revisión de las POLST
Se recomienda una revisión periódica de las POLST. Una revisión se recomienda cuando:
• se traslada a la persona de un lugar de atención o nivel de atención a otro o
• hay un cambio sustancial en el estado de salud de la persona o
• cambian las preferencias de tratamiento de la persona.
Cómo modificar y anular las POLST
• Un paciente con capacidad puede, en cualquier momento, solicitar un tratamiento alternativo.
• Un paciente con capacidad puede, en cualquier momento, revocar las POLST por cualquier medio que indique la intención de revocarlas.
•
Se recomienda que se documente la revocación: trace una línea a través de las secciones A a D, escriba “VOID” (anulado) en letra grande,
y firme y escriba la fecha en esta línea.
Un encargado de tomar decisiones reconocido legalmente podría solicitar modificar las órdenes en colaboración con el médico, basándose
en los deseos conocidos de la persona o, si no se conocen, en el mejor interés de la persona.
Este formulario está aprobado por la Dirección de Servicios Médicos de Emergencia de California en colaboración con el grupo de trabajo POLST de todo el estado.
Para obtener más información o una copia del formulario, visite www.caPOLST.org.
Enviar el formulario con la persona si se le trasladada o da de alta
CA POLST Form – Spanish
California Advance
Health Care Directive
This form lets you have a say about how
you want to be treated if you get very sick.
n This form has 3 parts. It lets you:
Part 1: Choose a health care agent.
A health care agent is a person
who can make medical decisions for you
if you are too sick to make them yourself.
Part 2: Make your own health care choices.
This form lets you choose the kind of health care you want.
This way, those who care for you will not have to guess
what you want if you are too sick to tell them yourself.
Part 3: Sign the form.
It must be signed before it can be used.
You can fill out Part 1, Part 2, or both.
Fill out only the parts you want. Always sign the form in Part 3.
2 witnesses need to sign on page 10 or a notary public on page 11.
Go to the next page
1
California Advance Health Care Directive
If you only want a health care agent go to Part 1 on page 3.
If you only want to make your own health care choices go to Part 2 on page 6.
If you want both then fill out Part 1 and Part 2.
Always sign the form in Part 3 on page 9.
2 witnesses need to sign on page 10 or a notary public on page 11.
n
What do I do with the form after I fill it out?
Share the form with those who care for you:
• doctors
• nurses
• social workers
n
• family & friends
• health care agent
What if I change my mind?
• Fill out a new form.
• Tell those who care for you about your changes.
• Give the new form to your health care agent and doctor.
n
What if I have questions about the form?
• Bring it to your doctors, nurses, social workers, health care agent,
family or friends to answer your questions.
n
What if I want to make health care choices
that are not on this form?
• Write your choices on a piece of paper.
• Keep the paper with this form.
• Share your choices with those who care for you.
2
California Advance Health Care Directive
PART 1
Choose your health care agent
The person who can make medical decisions for you
if you are too sick to make them yourself.
n
Whom should I choose to be my health care agent?
A family member or friend who:
• is at least 18 years old
• knows you well
• can be there for you when you need them
• you trust to do what is best for you
• can tell your doctors about the decisions you made on this form
Your agent cannot be your doctor or someone who works at your hospital or clinic,
unless he/she is a family member.
n
What will happen if I do not choose a health care agent?
If you are too sick to make your own decisions,
your doctors will ask your closest family members
to make decisions for you.
If you want your agent to be someone other than family,
you must write his or her name on this form.
n
What kind of decisions can my health care agent make?
Agree to, say no to, change, stop or choose:
• doctors, nurses, social workers
• hospitals or clinics
• medications, tests, or treatments
• what happens to your body and organs after you die
Your agent will need to follow the health care choices you make in Part 2.
Go to the next page
3
Part 1: Choose your health care agent
Other decisions your agent can make:
n
Life support treatments – medical care
to try to help you live longer
• CPR or cardiopulmonary resuscitation
cardio = heart
pulmonary = lungs
resuscitation = to bring back
This may involve:
– pressing hard on your chest to keep your blood pumping
– electrical shocks to jump start your heart
– medicines in your veins
• Breathing machine or ventilator
The machine pumps air into your lungs and breathes for you.
You are not able to talk when you are on the machine.
• Dialysis
A machine that cleans your blood if your kidneys stop working.
• Feeding Tube
A tube used to feed you if you cannot swallow. The tube is placed
down your throat into your stomach. It can also be placed by surgery.
• Blood transfusions
To put blood in your veins.
• Surgery
• Medicines
n
End of life care
– if you might die soon your health care agent can:
– call in a spiritual leader
– decide if you die at home or in the hospital
Show your health care agent this form.
Tell your agent what kind of medical care you want.
4
Go to the next page
Part 1: Choose your health care agent
Your Health Care Agent
n
I want this person to make my medical decisions.
first name
last name
street address
city
(
)
–
(
home phone number
n
–
work phone number
first name
last name
street address
city
)
–
home phone number
n
)
zip code
If the first person cannot do it, then I want this person to make my medical decisions.
(
n
state
(
state
)
zip code
–
work phone number
Put an X next to the sentence you agree with.
o
My health care agent can make decisions for me right after I sign this form.
o
My health care agent will make decisions for me only after I cannot make my own decisions.
You may write down your health care choices on this form. How do you want your health
care agent to follow these choices? Put an X next to the one sentence you most agree with.
o
I want my health care agent to work with my doctors and to use her/his best judgment.
It is OK for my agent to follow my health care choices on this form as a general guide.
Even though it is OK to follow my choices as a general guide, there are some choices
I do not want changed:
o
I want my health care agent to follow my health care choices on this form exactly. I never
want my agent to change my choices, even if the doctors think this is not good for me.
To make your own health care choices go to Part 2 on the next page.
To sign this form go to Part 3 on page 9.
5
California Advance Health Care Directive
PART 2
Make your own health care choices
Write down your choices so those who care for you will not have to guess.
n
Think about what makes your life worth living.
o
My life is only worth living if I can:
Put an X next to all the sentences you most agree with.
m talk to family or friends
m
wake up from a coma
m feed, bathe, or take care of myself
m be free from pain
m live without being hooked up to machines
m I am not sure
or
o
n
If I am dying, it is important for me to be:
o
n
at home
o
in the hospital
o
I am not sure
Is religion or spirituality important to you?
o
n
My life is always worth living no matter how sick I am
no
o
yes
If you have one, what is your religion?
What should your doctors know about your religion or spirituality?
If you are sick, your doctors and nurses will always
try to keep you comfortable and free from pain.
6
Go to the next page
Part 2: Make your own health care choices
Life support treatments are used to try to keep you alive. These can be CPR,
a breathing machine, feeding tubes, dialysis, blood transfusions, or medicine.
Put an X next to the one choice you most agree with.
Please read this whole page before you make your choice.
n If I am so sick that I may die soon:
o
Try all life support treatments that my doctors think might help.
If the treatments do not work and there is little hope of
getting better, I want to stay on life support machines.
or
o
Try all life support treatments that my doctors think might help.
If the treatments do not work and there is little hope of
getting better, I do not want to stay on life support machines.
or
o
Try all life support treatments that my doctors think might help
but not these treatments. Mark what you do not want.
m
m
m
m
CPR
dialysis
breathing machine
m
m
m
feeding tube
blood transfusion
medicine
other treatments
or
o
I do not want any life support treatments.
o
I want my health care agent to decide for me.
o
I am not sure.
or
or
Go to the next page
7
Part 2: Make your own health care choices
Your doctors may ask about organ donation and autopsy after you die.
Please tell us your wishes.
Put an X next to the one choice you most agree with.
n
Donating (giving) your organs can help save lives.
o
I want to donate my organs.
Which organs do you want to donate?
m
m
n
any organ
only
o
I do not want to donate my organs.
o
I want my health care agent to decide.
o
I am not sure.
An autopsy can be done after death to find out why someone died.
It is done by surgery. It can take a few days.
n
o
I want an autopsy.
o
I do not want an autopsy.
o
I want an autopsy if there are questions about my death.
o
I want my health care agent to decide.
o
I am not sure.
What should your doctors know about how you want your body
to be treated after you die?
8
Go to Part 3 on the next page to sign this form
California Advance Health Care Directive
PART 3
n
Sign the form
Before this form can be used, you must:
• sign this form
• have two witnesses sign the form
If you do not have witnesses, a notary public must sign on page 11.
A notary public’s job is to make sure it is you signing the form.
n
Sign your name and write the date.
/
sign your name
n
print your last name
address
city
state
zip code
Your witnesses must:
be over 18 years of age
know you
see you sign this form
Your witnesses cannot:
•
•
•
•
n
date
print your first name
•
•
•
n
/
be your health care agent
be your health care provider
work for your health care provider
work at the place that you live (if you live in a nursing home go to page 12)
Also, one witness cannot:
•
•
be related to you in any way
benefit financially (get any money or property) after you die
Witnesses need to sign their names on the next page.
If you do not have witnesses, take this form to a notary public
and have them sign on page 11.
9
Part 3: Sign the form
Have your witnesses sign their
names and write the date
By signing, I promise that
signed this form while I watched.
(name)
He/she was thinking clearly and was not forced to sign it.
I also promise that:
•
•
•
•
•
•
I know him/her or this person could prove who he/she was
I am 18 years or older
I am not his/her health care agent
I am not his/her health care provider
I do not work for his/her health care provider
I do not work where his/her lives
One witness must also promise that:
•
•
n
I am not related to his/her by blood, marriage, or adoption
I will not benefit financially (get any money or property) after he/she dies
Witness #1
/
sign your name
n
/
date
print your first name
print your last name
address
city
state
zip code
Witness #2
/
sign your name
/
date
print your first name
print your last name
address
city
state
zip code
You are now done with this form.
Share this form with your doctors, nurses,
social workers, friends, family, and
health care agent.
10
Talk with them about your choices.
Part 3: Sign the form
NOTARY PUBLIC
n
Take this form to a notary public ONLY
if two witnesses have not signed this form.
n Bring photo I.D. (driver’s license, passport, etc.)
You are now done with this form.
Share this form with your doctors, nurses,
social workers, friends, family, and
health care agent.
Talk with them about your choices.
11
California Advance Health Care Directive
For California Nursing Home Residents ONLY
n
Give this form to your nursing home director only if you live in a nursing home.
n
California law requires nursing home residents to have the nursing home
ombudsman as a witness of advance directives.
STATEMENT OF THE PATIENT ADvOCATE OR OMBUDSMAN
“I 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 Section 4675 of the Probate Code.”
/
sign your name
/
date
print your first name
print your last name
address
city
state
zip code
This advance directive is in compliance with the California Probate Code, Section 4671-4675. http://www.leginfo.ca.gov/calaw.html
12
This work is licensed under the Creative Commons Attribution-NonCommercial-ShareAlike License. To view a copy of this license,
visit http://creativecommons.org/licenses/by-nc-sa/2.0/ or send a letter to Creative Commons, 559 Nathan Abbott Way, Stanford, California 94305, USA.
Revised 1/18/2010
Designed by Rebecca Sudore, MD & Mahat Papartassee for the San Francisco Department of Public Health
Instrucción anticipada de
atención de salud de California
Este formulario le permite indicar la manera en que
desea que lo traten si está muy enfermo.
e Este formulario consta de 3 partes.
Le permite:
Parte 1: Escoger a un apoderado de atención de salud.
Un apoderado de atención de salud es una persona que puede
tomar decisiones médicas por usted si está muy enfermo para
tomarlas por usted mismo.
Parte 2: Tomar sus propias decisiones en cuanto
a su atención de salud.
Este formulario le permite escoger el tipo de atención de salud que desea.
De esta manera, las personas encargadas de su cuidado no tendrán que
adivinar lo que desea si está muy enfermo para decirlo por usted mismo.
Parte 3: Firmar el formulario.
Se debe firmar antes de que se pueda usar.
Usted puede llenar la Parte 1, la Parte 2 ó ambas.
Llene sólo las partes que desee. Siempre
firme el formulario en la Parte 3.
Vaya a la página siguiente.
1
Instrucción anticipada de atención de salud de California
Si sólo desea un apoderado de atención de salud, vaya a la Parte 1 en la página 3.
Si sólo desea tomar sus propias decisiones de atención de salud, vaya a la Parte 2
en la página 6.
Si desea hacer ambas cosas, llene la Parte 1 y la Parte 2.
Siempre firme el formulario en la Parte 3 que está en la página 9.
e
¿Qué hago con el formulario después de llenarlo?
Compártalo con aquellos encargados de su cuidado:
• médicos
• enfermeras
• trabajadores sociales
• familiares
• amigos
e
¿Qué sucede si cambio de opinión?
• Cambie el formulario.
• Informe sobre los cambios a aquellos encargados
de su cuidado.
e
¿Qué sucede si tengo preguntas sobre el formulario?
• Hágaselas a los médicos, enfermeras,
trabajadores sociales, familiares o amigos
para que se las respondan.
e
¿Qué sucede si tengo decisiones de atención de
salud que no aparecen en este formulario?
• Escriba sus decisiones en una hoja.
• Mantenga la hoja junto a este formulario.
• Comparta sus decisiones con aquellos encargados de su cuidado.
2
PARTE 1
Escoja su apoderado
de atención de salud
La persona que puede tomar decisiones médicas por usted
si está muy enfermo para tomarlas por usted mismo.
e
¿A quién debo escoger como mi apoderado de atención de salud?
Un familiar o amigo que:
• tenga 18 años o más de edad
• lo conozca bien
• pueda estar con usted cuando lo necesite
• usted confíe que hará lo mejor para usted
• pueda informarle a los médicos sobre las decisiones
que tomó en este formulario
Su apoderado no puede ser su médico o alguien que trabaje en el hospital o clínica,
a menos que sea un familiar.
e
¿Qué sucede si no escojo a un apoderado de atención de salud?
Si está muy enfermo como para tomar sus propias decisiones,
los médicos le pedirán a sus familiares más íntimos que
tomen las decisiones por usted.
Si desea que su apoderado no sea un familiar, debe
escribir su nombre en este formulario.
e
¿Qué tipo de decisiones puede tomar mi apoderado
de atención de salud?
Aceptar, rechazar, cambiar, suspender o escoger:
• médicos, enfermeras, trabajadores sociales
• hospitales o clínicas
• medicamentos o exámenes
• lo que sucederá con su cuerpo y órganos
después de su muerte
Vaya a la página siguiente.
3
Parte 1: Escoja a un apoderado de atención de salud
Otras decisiones que su apoderado puede tomar:
e
Tratamientos de mantenimiento de vida: tratamiento médico para
ayudarle a vivir más tiempo.
• CPR o reanimación cardiopulmonar
cardio = corazón
pulmonar = pulmones
resucitación = reanimación
Esto puede incluir:
– presionar con fuerza su pecho para mantener la circulación
de la sangre
– choque eléctrico para hacer que su corazón vuelva a funcionar
– medicamentos a través de sus venas
• Respirador artificial
El respirador bombea aire a sus pulmones y respira por usted. Usted
no puede hablar cuando se encuentra conectado al respirador.
• Diálisis
Una máquina que limpia su sangre si sus riñones dejan de funcionar.
• Sonda de alimentación
Una sonda que se usa para alimentarle si no puede tragar.
Esta sonda se inserta por la garganta hasta su estómago.
También se puede colocar con una cirugía.
• Transfusiones de sangre
Poner sangre en sus venas.
• Cirugía
• Medicamentos
e
Cuidados paliativos: Si existe la posibilidad de que muera pronto su apoderado
de atención de salud puede:
– llamar a un consejero espiritual
– decidir si muere en su casa o en el hospital
Comparta este formulario con su apoderado de atención de salud.
Dígale a su apoderado el tipo de tratamiento médico que desea.
4
Vaya a la página siguiente.
Parte 1: Escoja a un apoderado de atención de salud
Su apoderado de atención de salud
e
Yo deseo que esta persona ayude a tomar mis decisiones médicas.
nombre
apellido
dirección
(
)
ciudad
–
(
número de teléfono particular
e
estado
)
código postal
–
número de teléfono del trabajo
Si la primera persona no lo puede hacer, entonces deseo que esta persona
ayude a tomar mis decisiones médicas.
nombre
apellido
dirección
(
)
ciudad
–
número de teléfono particular
e
estado
(
)
código postal
–
número de teléfono del trabajo
Marque con una X la frase con la cual esté de acuerdo.
❏
Mi apoderado de atención de salud puede tomar decisiones por mí ahora.
❏
Mi apoderado de atención de salud tomará decisiones por mí sólo cuando
yo no pueda tomar las decisiones por mí mismo.
Para tomar sus propias decisiones de atención de salud, vaya a la Parte 2
de la página siguiente.
Para firmar este formulario vaya a la Parte 3 en la página 9.
5
Instrucción anticipada de atención de salud de California
PARTE 2
Tome sus propias decisiones
de atención de salud
Escriba sus decisiones de manera que aquellos encargados de su cuidado
no tengan que adivinar.
e
Piense en las cosas que hacen que su vida valga la pena. Marque con
una X todas las frases con las cuales esté más de acuerdo.
❏
Mi vida sólo vale la pena si puedo:
❍ conversar con mi familia o amigos
❍ despertar de un estado de coma
❍ alimentarme, bañarme y cuidar de
mí mismo
❍ no sentir dolor
❍ vivir sin estar conectado a máquinas
❍ no estoy seguro
e
Si estoy muriendo, es importante para mí estar:
❏
e
❏
en el hospital
❏
no estoy seguro
¿Es importante para usted la religión o la espiritualidad?
❏
e
en casa
Sí
❏
No
¿Qué deben saber los médicos sobre su religión o espiritualidad?
Si está enfermo, sus médicos y enfermeras siempre
intentarán mantenerlo lo más cómodo posible y sin dolor.
6
Vaya a la página siguiente.
Parte 2: Tome sus propias decisiones de atención de salud
Los tratamientos de mantenimiento de vida se usan para mantenerlo vivo.
Éstos pueden ser CPR, un respirador artificial, sondas de alimentación, diálisis,
transfusiones de sangre o medicamentos.
Marque con una X las frases con las cuales esté más de acuerdo.
Lea toda esta página antes de tomar sus decisiones.
e Si estoy muy enfermo y puedo morir pronto:
❏
Deseo que se intenten todos los tratamientos de mantenimiento
de vida que mis médicos crean que pueden ayudar.
Si los tratamientos no funcionan y existe una mínima
esperanza de mejorarme, deseo que me conecten
a máquinas de mantenimiento de vida.
❏
Deseo que se intenten todos los tratamientos de mantenimiento
de vida que mis médicos crean que pueden ayudar.
Si los tratamientos no funcionan, y existe una mínima esperanza de
mejorarme, no deseo que me conecten a máquinas de mantenimiento de vida.
❏
Deseo que se intenten todos los tratamientos de mantenimiento de vida que
mis médicos crean que pueden ayudar, pero no los siguientes. Marque los
tratamientos que no desee.
❍
❍
❍
❍
CPR
diálisis
respirador artificial
❍
❍
❍
sonda de alimentación
transfusión de sangre
medicamentos
otros tratamientos
❏
No deseo ningún tratamiento de mantenimiento de vida.
❏
Deseo que mi apoderado de atención de salud decida por mí.
❏
No estoy seguro.
Vaya a la página siguiente.
7
Parte 2: Tome sus propias decisiones de atención de salud
Sus médicos pueden preguntar sobre la donación de órganos y autopsia
después de morir. Infórmenos sus deseos.
Marque con una X las frases con las cuales esté más de acuerdo.
e
Donar (dar) sus órganos puede ayudar a salvar vidas.
❏
Deseo donar mis órganos.
¿Qué órganos desea donar?
❍
❍
e
e
cualquier órgano
sólo
❏
No deseo donar mis órganos.
❏
Deseo que mi apoderado de atención de salud decida.
❏
No estoy seguro.
Se puede realizar una autopsia después de la muerte para saber por qué
murió una persona. Se realiza mediante una cirugía.
Puede tardar algunos días.
❏
Deseo una autopsia.
❏
No deseo una autopsia.
❏
Es posible que desee una autopsia si existe alguna duda sobre mi muerte.
❏
Deseo que mi apoderado de atención de salud decida.
❏
No estoy seguro.
¿Qué deben saber sus médicos sobre la forma en que desea se trate
8
Vaya a la Parte 3 en la página siguiente para firmar este formulario.
PARTE 3 Firme el formulario
e
Antes de que se pueda usar este formulario, usted debe:
• firmarlo
• decirle a dos testigos que lo firmen
Si no tiene testigos, tendrá que ser ante un notario público.
El trabajo del notario público es asegurarse de que sea usted
quien firma el formulario.
e
Firme e indique la fecha.
firma
fecha
nombre en letra de molde
apellido en letra de molde
dirección
e
e
ciudad
estado
código postal
Su testigo debe:
•
•
•
e
/
/
ser mayor de 18 años
conocerlo
verlo firmar este formulario
Su testigo no puede:
•
ser su apoderado de atención de salud, médico, enfermera ni trabajador social
•
•
beneficiarse financieramente (obtener dinero) después de su muerte
trabajar en el lugar donde vive
(si vive en una casa de reposo, vaya a la página 12)
Sólo uno de los testigos puede ser un familiar.
Los testigos tienen que firmar la página siguiente.
Si no tiene testigos, lleve este formulario a un notario público y
pídale que firme la página 11.
9
Parte 3: Firme el formulario
Pídale a sus testigos que
firmen e indiquen la fecha.
e
Testigo 1
/
firma
fecha
nombre en letra de molde
apellido en letra de molde
dirección
e
/
ciudad
Testigo 2
estado
/
código postal
/
firma
fecha
nombre en letra de molde
apellido en letra de molde
dirección
ciudad
estado
código postal
Ha terminado de llenar este formulario.
Comparta este formulario con sus médicos,
enfermeras, trabajadores sociales, amigos
y familiares.
10
Converse con ellos sobre sus decisiones.
NOTARIO PÚBLICO
e
Lleve este formulario a un notario público SÓLO
si no lo han firmado dos testigos.
e
Traiga una identificación con fotografía
(licencia de conducir, pasaporte, etc.)
CERTIFICATE OF ACKNOWLEDGEMENT OF NOTARY PUBLIC
STATE OF CALIFORNIA
County of
On this
day of
in the year
before me
(print name of notary public)
personally appeared
(print name of person completing this form)
and has proved to me on the basis of satisfactory evidence, to be the person whose name is
indicated on this advance health care directive, and has stated that he or she did complete
this form. I declare under penalty of perjury, that the person, whose name is indicated in
the advance health care directive, appears to be of sound mind and is under no duress,
fraud, or undue influence.
NOTARY SEAL
(Signature)
(Date)
Ha terminado de llenar este formulario.
Comparta este formulario con sus médicos,
enfermeras, trabajadores sociales, amigos
y familiares.
Converse con ellos sobre sus decisiones.
11
Instrucción anticipada de atención de salud de California
SÓLO para residentes de casas de reposo
del estado de California
e
Entréguele este formulario al director de su casa de reposo, sólo si vive en una.
e
La ley del estado de California exige que los residentes de una casa
de reposo tengan como testigo de las instrucciones anticipadas
al defensor legal (ombudsman) de la casa de reposo.
DECLARACIÓN DEL DEFENSOR LEGAL (OMBUDSMAN) DEL PACIENTE
“Declaro bajo pena de perjurio en conformidad con las leyes del
estado de California que soy el defensor legal (ombudsman)
del paciente designado por el Departamento Estatal de Edad
Avanzada y que estoy sirviendo como testigo según lo estipulado
/
/
firma
fecha
nombre en letra de molde
apellido en letra de molde
dirección
ciudad
estado
código postal
12
Diseñado por Rebecca Sudore, MD & PM Creativa para el Departamento de Salud Pública del San Francisco