Advance care planning in California: the directive, the agent and the conversation

Advance care planning is how you make sure the people caring for you know what you want, if a day comes when you can’t tell them yourself. It’s a conversation first and a document second. In California, the main document is the advance health care directive. This note explains the state’s form, how to sign it, where to keep it, how it differs from a POLST, and the conversation that makes it work.

The short answer

• California’s advance health care directive lets you name an agent to make health care decisions for you, give instructions about your care, or both.¹
• You can complete all of the form or any part of it.¹
• It must be signed by two qualified witnesses or acknowledged before a notary public.¹
• You can revoke it or replace it at any time.¹
• Medicare covers advance care planning as part of a yearly wellness visit, and you pay nothing when the provider accepts assignment.²

What the form does

The California form does two main things, and you can use either one or both.¹

• It names your agent. This is the person who makes health care decisions for you when you can’t. You can name alternates too, in case your first choice isn’t available.
• It records your instructions. This is where you write what you want and don’t want, in your own words if you like.

It also lets you state your wishes about organ donation and name your primary physician.¹

By default, your agent’s authority begins when your primary physician determines that you can’t make your own health care decisions. The form also lets you choose to have it take effect right away.¹

Choosing your agent

Pick someone who knows you well, who will follow your wishes even when they’d choose differently, who can stay steady when doctors and family disagree, and who’s likely to be reachable when it matters. It doesn’t have to be your oldest child or your spouse. It has to be the person you trust to speak for you.

There are limits on who can serve. Generally, your supervising health care provider and people who operate or work at the facility where you receive care can’t be your agent, unless they’re related to you or a coworker.¹

Then tell them. An agent who has never heard your wishes is guessing.

Signing it

The form must be signed by two qualified witnesses, or acknowledged before a notary public.¹ The person you name as your agent can’t be a witness, and at least one witness must not be related to you by blood, marriage or adoption, and not entitled to any part of your estate.¹

If you live in a skilled nursing facility, there’s one more step. A patient advocate or ombudsman must sign an additional statement.¹

The form is written so people can fill it out themselves. You can also talk about an advance directive with an attorney or your health care provider.²

Where to keep it

A directive only helps if people can find it.

• Give a copy to your physician and your other health care providers, to any facility where you receive care, and to your agent and alternates.¹
• Keep the original somewhere easy to reach at home, and tell your agent where it is.
• Bring a copy to every hospital stay and every new doctor.

California also offers an optional registry. You can register your directive with the Secretary of State by mail, for a $10 fee. Registering is entirely voluntary, and only you, your health care providers, your guardian or conservator and the agents named in your current directive can see your registry information.³

The conversation

The form is the easy part. The conversation is what makes it work. These questions help:

• What matters most to you, now and if you become seriously ill?
• What are you most afraid of?
• If you were very sick, would you want every treatment that might extend your life, or would you put comfort first?
• Where would you want to be cared for at the end of life?
• Who do you want involved in decisions, and who would you rather not burden?
• Are there spiritual or cultural wishes your care should honor?

Write the answers in the directive, in your own words, and share them with your agent. Then come back to them when life changes: a new diagnosis, a hospital stay, a move, or a change in who you’d want speaking for you. You can revoke or replace the directive at any time.¹

Advance directive and POLST

The two do different jobs.⁴

• An advance directive is for any adult. It names your agent and records your wishes for the future, and it doesn’t need a clinician’s signature.
• A POLST is for someone who is seriously ill. It turns their wishes into medical orders for now, signed with a physician, nurse practitioner or physician assistant, and it tells emergency crews what to do today.

Most people with a serious illness should have both. The POLST covers the emergency. The directive names who speaks for you about everything else. Our POLST note explains how to fill one out.

When someone is already seriously ill

If your loved one is already seriously ill, don’t wait for a calm moment that may not come. Ask their doctor to set aside time for the conversation, and ask whether a POLST makes sense now.⁴ If they’re on palliative care or hospice, the social worker and the nurse can help the family talk it through and put the answers in writing.

Medicare pays for the conversation

Medicare covers voluntary advance care planning. When it’s part of your yearly wellness visit and your provider accepts assignment, you pay nothing. When it’s part of other medical treatment, the Part B deductible and coinsurance apply.² Ask for it by name at your next wellness visit.