Advance Directive For Health Care (Page 5 of 7) in pdf

Advance Directive For Health Care Page 5

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

ADVANCE DIRECTIVE FOR HEALTH CARE

CDCR 7421 (REV. 09/09)

PART 3: Donation of Organs at Death (Optional)

Upon my death (if you wish to donate organs, check the box that applies to your wish):

(a) I give any needed organs, tissues, or parts, OR

(b) I give the following organs, tissues, or parts only. (List organs, tissues, or parts you want to

donate). __________________________________________________________________________

My gift is for the following purposes (cross out any of the following you do not want):

(1) Transplant

(3) Research

(2) Therapy

(4) Education

PART 4: Verification of Understanding, Signature, Witnesses

Verification of Effective Communication

(To be completed by medical staff)

I have met with the patient-inmate and communicated the purpose of this Advance Directive and

discussed the decisions he/she is making regarding his/her future health care and he/she:

Has no identified effective communication assistance need and appears to understand.

Has the following effective communication need: ____________________________

(i.e., Developmental or Learning Disability, Physical, or Mental Disability impacting communication - hearing,

vision, speech).

This need was met by:

Providing preferred method of communication in explaining this form

Speaking slowly, using simple language, and having the patient explain in own

words his or her understanding of this form.

Other accommodations – specify: _____________________________________.

________________________________ _________________________________ ______________

Staff Printed Name

Staff Signature

Date

Distribution: Original-UHR, Copy to Inmate

Page 5 of 7

Advance Directive For Health Care Page 5