My Care My Plan Sonoma

Answers to Frequently Asked Questions

We hope the following FAQs will help you to start developing your own Advance Care Plan. You can find links to expert local, state and national Advance Care Planning resources on the Resources page. You’ll find information on starting conversations about your health care wishes, the option of choosing a health care agent, what to include in an Advance Health Care Directive, links to downloadable Advance Health Care Directive forms, and more.

What is Advance Care Planning?

Advance Care Planning is a process of reflection and communication. It leads to development of a personal Advance Health Care Directive, a legal document intended to guide medical decisions.
  • Advance Care Planning involves exploring your wishes, expressing your wishes and preparing others to honor your wishes.
  • It is a conversation that takes place over time and is better done in the living room rather than a hospital room.
Who Should You Talk to about Your Advance Care Planning Wishes? (Video)

What is an Advance Health Care Directive?

An Advance Health Care Directive provides a way to make your health care wishes known when you are no longer able to communicate your choices.
  • It allows you to specify what kinds of treatments you might want under certain circumstances.
  • It also allows you to name a willing person(s) — if you choose to do so — as your health care agent to speak on your behalf as if they were you and work with your doctor to make decisions for your care.
  • A completed directive is useful only if it is available when it is needed. It should be readily accessible and shared, at a minimum, with your doctor and health care agent, not kept secret or stored away.
Although an Advance Health Care Directive is a legal document, you do not need an attorney to complete one. However, to make your directive legal, it needs to be to be signed by two witnesses or notarized by a licensed Notary Public. Witnesses must be different from your health care agent(s).

Because situations often change, it’s important to regularly review and update your Advance Health Care Directive and advise your doctor(s) and health care agent of changes. Some people mark a memorable date on their calendars to review their directive annually.

Where do I find the Advance Care Directive form?

Forms are available at My Care, My Plan events. You can also download forms by visiting the links on our Resources page . Since in California there is no one required Advance Health Care Directive form, you may want to review several to choose the one you like best. Many websites offer forms in English, Spanish, Chinese, and other languages.

What happens if I don’t have an Advance Health Care Directive?

If you don’t have a directive and become unable to speak in a medical situation, physicians will generally try to locate your family members, friends or clergy to make decisions about your care. If physicians are unable to locate anyone willing to speak on your behalf, a hospital ethics panel or a court may make decisions for you. Speak up now — so someone you choose can speak for you in the future.

When should I complete Advance Care Planning or an Advance Health Care Directive?

If you’re 18 or older, the sooner, the better. No one can predict when accident or illness may leave you unable to communicate your choices to your loved ones and/or physician.

When would the provisions in my Advance Health Care Directive go into effect?

Most people choose to have their Advance Health Care Directives go into effect only if they lose the ability to communicate or understand decisions about their care. If you have a health care agent, you can choose to allow him/her to speak for you at any time, even if you can understand, make and communicate your own decisions.

What if I want to change my Advance Health Care Directive?

Your directive can be revised any time up until your ability to make and communicate health care decisions is lost. You have the right to change your document as many times as you want. Simply complete a new document and destroy the old one. Your most recently dated directive is the one that is legally valid and will be acted upon. Make sure your loved ones, health care agent, physician(s) and caregiver(s) get a copy of the most recent version.

What is a health care agent?

Someone over age 18 to whom you give the authority to make health care decisions should you become unable or unwilling to communicate for yourself. These decisions include:
  • Choosing your doctor or other health care provider, and where you will receive care.
  • Speaking with your health care team about your condition and treatment options.
  • Reviewing your medical record and authorizing its release when needed.
  • Accepting or refusing medical treatments for you, including artificial nutrition and hydration, and CPR.
  • Consenting to tissue and organ donation, authorizing an autopsy and arranging for care of your body after death.

It is advisable, but optional, to name a health care agent.

For additional information “Do I need to name a health care agent?”

Who should I choose as my health care agent?

Choose an adult you trust to best represent your wishes. This may be a relative or a friend. Or, you could select an attorney or fiduciary. It is vital to communicate with your agent about your wishes through Advance Care Planning conversations. Make sure they can advocate for the type of care you want. The more you discuss your wishes with your agent, the better he/she will be able to make decisions on your behalf should you become unable to speak for yourself.

Do I need to name a health care agent?

Selecting a health care agent is optional. However, if you have a relative or friend you believe would properly represent your wishes and he/she is comfortable serving in this role, it is highly advisable to name an agent in your Advance Health Care Directive. Some people choose an attorney or fiduciary if they don’t have a relative or friend who they would choose for this role. A health care agent will help increase the likelihood that your wishes will be honored. If you don’t name an agent, it is still important to complete a directive so you can document and share your wishes with your doctor.

Who Should You Talk to about Your Health Care Wishes? (Video)

What is a POLST? Do I also need a “Do Not Resuscitate” form?

If you or your loved one has a chronic, progressive, serious health condition, is of advanced age or medically frail, you should know about this additional medical form that speaks for you if you cannot speak for yourself. POLST stands for Physician's Orders for Life-Sustaining Treatment and needs to be completed in conversation with your doctor. Both you and your doctor must sign the completed POLST to make it legally valid. The POLST is recognized in health care systems throughout California. It is essentially a portable care plan that moves with an individual from one care setting to another. POLST is printed on bright pink paper to stand out. It can replace a "Do Not Resuscitate" form.

When needed, a POLST does not replace, but complements an Advance Health Care Directive.