For Patients

Advance Directive

An advance health care directive lets your physician, family and friends know your healthcare preferences, including the types of special treatment you want or do not want at the end of life, your desire for diagnostic testing, surgical procedures, cardiopulmonary resuscitation and organ donation. By considering your options early, you can ensure the quality of life that is important to you and avoid having your family make critical medical care decisions for you under stress or in emotional turmoil.

Part 1 of this form is a power of attorney for healthcare. This lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions.

Part 2 of this form lets you give specific instructions about any aspect of your healthcare, whether or not you appoint an agent. Choices are provided as well as space for you to add to the choices you have made or for you to write out any additional wishes.

Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death.

Part 4 of this form lets you designate a physician to have primary responsibility for your healthcare.

After completing this form, sign and date the form at the end. You must have two witnesses present to sign the form as well or receive a certificate of acknowledgement before a notary public.

Advance Directive English Form
Advance Directive Spanish Form

Five Wishes

Five Wishes

Five Wishes serves as an Advance Directive and is a legally-valid tool available for your use. Five Wishes helps ensure your wishes, and those of your loved ones, will be respected-even if you cannot speak for yourself. To learn more about Five Wishes, please contact Mission Hospital’s Spiritual Care department at (949) 364-1400 ext. 5399.

POLST (Physician Order for Life Sustaining Treatment)

A new law effective 1/1/16 allows Nurse Practitioners and Physician Assistants to sign the California POLST form. The form is now available in ENGLISH and will be available in other languages later in January, 2016. For more information visitwww.capolst.org

Click here for more information and to download a copy of the POLST in English, Spanish, Chinese, Vietnamese, Korean, Farsim Armenian, Russian, Tagalog and Hmong.

POLST Forms

Click here to download a 2016 California POLST form in English.