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ADVANCE HEALTH CARE DIRECTIVE

Advance Directive  ·  State Of California  ·  Cal. Prob. Code §§4600-4805 (Advance Health Care Directive)  ·  Patient Self-determination Act, 42 U.S.C. §§1395Cc(f), 1396A(w)

This Advance Health Care Directive is entered into by Margaret Anne Sullivan (the "Principal"), born April 12, 1952, residing at 742 Evergreen Terrace, Los Angeles, CA 90001, State of California, pursuant to Cal. Prob. Code §§4600-4805 (Advance Health Care Directive).

I, Margaret Anne Sullivan, being of sound mind and understanding the nature of this document, hereby designate Daniel Patrick Sullivan, my Spouse, of 742 Evergreen Terrace, Los Angeles, CA 90001 ((213) 555-0143 · daniel.sullivan@email.com), as my Healthcare Agent and Attorney-in-Fact for healthcare decisions (hereinafter "Agent"). My Agent is authorized to act on my behalf in all matters relating to my health, medical care, and treatment decisions as set forth herein.

Subject to the limitations set forth herein, my Agent is specifically authorized to:

  (a) make all healthcare decisions on my behalf, including consenting to, refusing, or withdrawing consent to any medical procedure, treatment, or intervention, including life-sustaining treatment;

  (b) admit, transfer, or discharge me from any hospital, nursing facility, hospice, or other healthcare facility;

  (c) hire, instruct, compensate, and discharge physicians, nurses, and other healthcare providers acting on my behalf;

  (d) access my medical records, test results, diagnoses, and treatment information from any healthcare provider, hospital, or facility;

  (e) make decisions about my care, comfort, and quality of life;

  (f) make decisions regarding mental health treatment, including voluntary admission to inpatient psychiatric facilities and consent to or refusal of psychiatric medications or therapies, to the extent permitted by Cal. Prob. Code §§4600-4805 (Advance Health Care Directive);

  (g) take all other actions reasonably necessary to carry out my healthcare wishes as expressed herein or as otherwise known to my Agent.

My Agent's authority under this document is as broad as I am permitted to grant under Cal. Prob. Code §§4600-4805 (Advance Health Care Directive) and shall be construed liberally to accomplish my healthcare goals. Third parties may rely on my Agent's representations without independent investigation.

This advance health care directive shall become effective upon a written determination by my attending physician (or, where permitted by California law, a licensed clinical psychologist or nurse practitioner) that I lack sufficient capacity to make or communicate healthcare decisions. Such determination shall be documented in my medical record and shall state the nature, cause, and probable duration of my incapacity. My Agent's authority shall cease if I regain decision-making capacity. Until a formal determination of incapacity is made, I retain full authority over all of my healthcare decisions.

In accordance with the constitutionally protected liberty interest in refusing unwanted medical treatment recognized in In re Quinlan, 70 N.J. 10 (1976), and Cruzan v. Director, Mo. Dep't of Health, 497 U.S. 261 (1990), and pursuant to Cal. Prob. Code §§4600-4805 (Advance Health Care Directive) (a state enactment of the Uniform Health-Care Decisions Act), I provide the following specific instructions regarding life-sustaining treatment. These instructions shall apply when I have an irreversible condition from which there is no reasonable expectation of recovery, including terminal illness, permanent unconsciousness, or end-stage irreversible decline:

  (a) Resuscitation: I DO NOT WANT cardiopulmonary resuscitation (CPR), defibrillation, or resuscitative measures. If my heart stops or I stop breathing, allow natural death to occur without intervention. This instruction shall be communicated to my treating physician for appropriate clinical orders.

  (b) Mechanical Ventilation: I DO NOT WANT to be placed on mechanical ventilation. If I am already receiving ventilator support and my attending physician and Agent agree there is no reasonable expectation of recovery of meaningful function, I authorize its removal.

  (c) Artificial Nutrition and Hydration: I DO NOT WANT artificial nutrition or hydration through feeding tubes or intravenous lines if I cannot eat or drink on my own and my condition is irreversible. I understand and accept that withholding such treatment may shorten my life, and I make this choice freely and knowingly pursuant to my constitutional right recognized in Cruzan v. Director, Mo. Dep't of Health, 497 U.S. 261 (1990).

  (d) Dialysis: I delegate the decision regarding dialysis to my Healthcare Agent.

  (e) Pain Management and Comfort Care: I want maximum comfort care, including aggressive palliative and pain-management measures consistent with hospice standards of care, even if such measures may incidentally hasten my death. My primary goal is relief from pain and suffering, not prolongation of life.

Clinical Note: These preferences are advance-directive instructions for my Agent and treating physicians. They do not substitute for a physician-signed DNR / DNAR order or a Physician/Medical Orders for Life-Sustaining Treatment (POLST / MOLST) form as authorized under the law of California. My Agent should work with my treating physician to execute appropriate clinical orders consistent with these instructions. Pregnancy Note: The State of California does not impose a statutory pregnancy override on this advance directive. My instructions above apply during pregnancy unless I expressly state otherwise. (Some other states impose statutory limitations; constitutional analysis is evolving post-Dobbs v. Jackson, 597 U.S. 215 (2022).)

I hereby designate my Healthcare Agent as my Personal Representative for all purposes under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 42 U.S.C. §1320d et seq., and its Privacy Rule implementing regulations at 45 C.F.R. §164.502(g)(1)-(3) (personal-representative access to PHI) and 45 C.F.R. §164.524 (right of access). Pursuant to this designation, I authorize and direct all physicians, hospitals, clinics, laboratories, pharmacies, health plans, and other covered entities and business associates to disclose to my Agent any and all Protected Health Information (PHI) concerning me, including:

  – medical records, diagnoses, test results, imaging, pathology, laboratory data, and treatment plans;
  – billing records and insurance information to the extent necessary to make or implement healthcare decisions;
  – records from prior, current, and future healthcare providers;
  – records concerning mental-health diagnoses and treatment;
  – separately maintained psychotherapy notes as defined at 45 C.F.R. §164.501 — I expressly authorize disclosure under 45 C.F.R. §164.508(a)(2);
  – This authorization does NOT extend to substance-use disorder records protected under 42 C.F.R. Part 2 (a separate, compliant consent is required);
  – HIV/AIDS status records to the extent permitted by applicable state law.

This HIPAA Authorization is effective immediately upon my signature and shall remain in effect until revoked in writing. It is not limited to periods of incapacity. Any healthcare provider relying in good faith on this authorization shall be held harmless.

If Daniel Patrick Sullivan (my primary Healthcare Agent) is deceased, mentally incapacitated, unwilling to serve, or unreachable at a time when healthcare decisions must be made, I hereby appoint Catherine Lynn Sullivan, my Daughter, of 210 Oak Street, Chicago, IL 60601 ((312) 555-0289) as my Successor Healthcare Agent with the same authority and subject to the same obligations as the primary Agent. The Successor Agent assumes authority only upon written confirmation of the primary Agent's inability or unwillingness to serve, or upon the treating physician's written certification that the primary Agent cannot be reached within a clinically appropriate time period.

  (a) Organ and Tissue Donation: I consent to the donation of the following specific organs and tissues upon my death: heart, kidneys, liver. This gift is made pursuant to the Revised Uniform Anatomical Gift Act (UAGA 2006) as adopted in California, for the purposes of transplantation, therapy, research, and education. No organs or tissues other than those listed above are donated.

  (b) Remains: I prefer that my remains be disposed of by cremation.

  (c) Additional Instructions: I would like a simple memorial service at Holy Name Cathedral. I wish my ashes to be placed at Rosehill Cemetery.

My Agent shall: (a) act in my best interest and consistent with my known values, religious beliefs, and expressed wishes; (b) make healthcare decisions as I would make them if I were able; (c) consult with my treating physicians and other healthcare professionals to obtain relevant medical information; (d) keep my healthcare information confidential and disclose it only as necessary to carry out my wishes; (e) not make decisions motivated by the Agent's personal convenience or financial gain; and (f) document significant healthcare decisions where practicable. My Agent shall be immune from civil or criminal liability for healthcare decisions made in good faith and consistent with the terms of this document and Cal. Prob. Code §§4600-4805 (Advance Health Care Directive).

I may revoke this advance directive at any time while I retain decision-making capacity, by: (a) executing a new advance directive; (b) notifying my Agent or treating physician orally or in writing; or (c) physically destroying this document. Revocation is effective upon communication to my Agent or any treating healthcare provider. A subsequent advance directive automatically revokes all prior advance directives unless it expressly provides otherwise. Healthcare providers who act in good faith reliance on this document prior to receiving written notice of revocation shall be held harmless.

This advance directive is intended to comply with the federal Patient Self-Determination Act of 1990, 42 U.S.C. §§1395cc(f), 1396a(w), and with Cal. Prob. Code §§4600-4805 (Advance Health Care Directive). Execution requirements: Two (2) witnesses OR notarization. Witnesses cannot be the named agent, healthcare provider, or operator of a community-care facility. At least one must not be a relative or beneficiary (Cal. Prob. Code §4674). If any provision is held invalid or unenforceable, the remaining provisions shall continue in full force and effect. If I receive healthcare in a state other than California, this document shall be honored to the fullest extent permitted by the laws of that state and any applicable interstate-recognition provisions (e.g., 42 U.S.C. §1395cc(f)(2)).

IN WITNESS WHEREOF, I, Margaret Anne Sullivan, declare that I am of legal age, of sound mind, acting voluntarily and free from duress, and that I understand the nature and effect of this advance health care directive.