Advance Directive For Health Care
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7STATE OF CALIFORNIA
DEPARTMENT OF CORRECTIONS AND REHABILITATION
ADVANCE DIRECTIVE FOR HEALTH CARE
CDCR 7421 (REV. 09/09)
Advance Directive for Health Care
Inmate Name: _____________________________________
Date: __________________________
CDC Number: _________________
Date of Birth: ___/___/____
Institution: ______________
What is an Advance Directive for Health Care?
Advance directive is a general term used for documents that traditionally include:
1. A “Durable Power of Attorney for Health Care” which allows you to choose someone to make
medical decisions for you when you are unable to make them yourself. This person is called
your “Agent” or “Proxy.”
2. A “Living Will” which allows you to state your goals or desires for the type(s) of health care
you want or do not want. Also called “Instructions for Health Care Form.”
(For more information see Inmate Fact Sheet/Instructions regarding CDCR Form 7421 Advance Directive for Health Care)
What are the parts of this form?
Selecting someone to speak for you. Who do you want to make decisions for you if you
Part 1:
are unable to make your own decisions? You may choose up to three people, or may
choose not to select anyone at this time.
What type of health care do you want if you are very sick and unable to tell your wishes
Part 2:
to the doctors and nurses? This usually refers to what are called “End-of-Life” decisions.
If you have a condition that is so serious that you are dying, do you want your doctors
and nurses to do everything possible to prolong your life or do you only want treatments
to keep you comfortable?
Part 3:
This allows you to choose whether or not you are willing to donate organs or other
tissues.
Part 4:
Before you sign the Advance Directive, a medical staff person must document that you
have been fully informed and understand this form. After you sign and date the form,
two people need to witness that you willingly signed the form and filled it out according
to your wishes (in rare circumstances the form can be notarized instead of using two
witnesses).
After completing the form what should I do? A copy will be placed in your Unit Health Record.
Keep a copy for yourself and give a copy of the Advance Directive for Health Care to any health care
agents you have named. You should talk to the person you have named as an agent to make sure that he
or she understands your wishes and is willing to take the responsibility.
How long is the form valid? It does not have an expiration date but you have the right to cancel this
advance health care directive or replace this form at any time. Also, a copy of this form is as good as
the original (if you wish to change or cancel, tell your medical provider).
Distribution: Original-UHR, Copy to Inmate
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