§327E-16 - Optional form.

§327E-16 Optional form. The following
sample form may be used to create an advance health-care directive. This form
may be duplicated. This form may be modified to suit the needs of the person,
or a completely different form may be used that contains the substance of the
following form.

"ADVANCE
HEALTH-CARE DIRECTIVE

Explanation

You have the right to give instructions about
your own health care. You also have the right to name someone else to make
health-care decisions for you. This form lets you do either or both of these
things. It also lets you express your wishes regarding the designation of your
health-care provider. If you use this form, you may complete or modify all or
any part of it. You are free to use a different form.

Part 1 of this form is a power of attorney for
health care. Part 1 lets you name another individual as agent to make
health-care decisions for you if you become incapable of making your own
decisions or if you want someone else to make those decisions for you now even
though you are still capable. You may name an alternate agent to act for you
if your first choice is not willing, able, or reasonably available to make
decisions for you. Unless related to you, your agent may not be an owner,
operator, or employee of a health-care institution where you are receiving
care.

Unless the form you sign limits the authority
of your agent, your agent may make all health-care decisions for you. This
form has a place for you to limit the authority of your agent. You need not limit
the authority of your agent if you wish to rely on your agent for all
health-care decisions that may have to be made. If you choose not to limit the
authority of your agent, your agent will have the right to:

(1) Consent or refuse consent to any care, treatment,
service, or procedure to maintain, diagnose, or otherwise affect a physical or
mental condition;

(2) Select or discharge health-care providers and
institutions;

(3) Approve or disapprove diagnostic tests, surgical
procedures, programs of medication, and orders not to resuscitate; and

(4) Direct the provision, withholding, or withdrawal
of artificial nutrition and hydration and all other forms of health care.

Part 2 of this form lets you give specific
instructions about any aspect of your health care. Choices are provided for
you to express your wishes regarding the provision, withholding, or withdrawal
of treatment to keep you alive, including the provision of artificial nutrition
and hydration, as well as the provision of pain relief medication. Space is
provided for you to add to the choices you have made or for you to write out
any additional wishes.

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

After completing this form, sign and date the
form at the end and have the form witnessed by one of the two alternative
methods listed below. Give a copy of the signed and completed form to your
physician, to any other health-care providers you may have, to any health-care
institution at which you are receiving care, and to any health-care agents you
have named. You should talk to the person you have named as agent to make sure
that he or she understands your wishes and is willing to take the
responsibility.

You have the right to revoke this advance
health-care directive or replace this form at any time.

PART 1

DURABLE POWER
OF ATTORNEY FOR HEALTH-CARE DECISIONS

(1) DESIGNATION OF AGENT: I designate the
following individual as my agent to make health-care decisions for me:

__________________________________________________________

(name of individual you choose as
agent)

__________________________________________________________

(address) (city) (state) (zip code)

__________________________________________________________

(home phone) (work phone)

OPTIONAL: If I revoke my agent's authority or
if my agent is not willing, able, or reasonably available to make a health-care
decision for me, I designate as my first alternate agent:

__________________________________________________________

(name of individual you choose as first
alternate agent)

__________________________________________________________

(address) (city) (state) (zip code)

__________________________________________________________

(home phone) (work phone)

OPTIONAL: If I revoke the authority of my
agent and first alternate agent or if neither is willing, able, or reasonably
available to make a health-care decision for me, I designate as my second
alternate agent:

__________________________________________________________

(name of individual you choose as second
alternate agent)

__________________________________________________________

(address) (city) (state) (zip code)

__________________________________________________________

(home phone) (work phone)

(2) AGENT'S AUTHORITY: My agent is authorized
to make all health-care decisions for me, including decisions to provide,
withhold, or withdraw artificial nutrition and hydration, and all other forms
of health care to keep me alive, except as I state here:

__________________________________________________________

(Add additional sheets if needed.)

(3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:
My agent's authority becomes effective when my primary physician determines
that I am unable to make my own health-care decisions unless I mark the
following box. If I mark this box [ ], my agent's authority to make
health-care decisions for me takes effect immediately.

(4) AGENT'S OBLIGATION: My agent shall make
health-care decisions for me in accordance with this power of attorney for
health care, any instructions I give in Part 2 of this form, and my other wishes
to the extent known to my agent. To the extent my wishes are unknown, my agent
shall make health-care decisions for me in accordance with what my agent
determines to be in my best interest. In determining my best interest, my
agent shall consider my personal values to the extent known to my agent.

(5) NOMINATION OF GUARDIAN: If a guardian
needs to be appointed for me by a court, I nominate the agent designated in
this form. If that agent is not willing, able, or reasonably available to act
as guardian, I nominate the alternate agents whom I have named, in the order
designated.

PART 2

INSTRUCTIONS
FOR HEALTH CARE

If you are satisfied to allow your agent to
determine what is best for you in making end-of-life decisions, you need not
fill out this part of the form. If you do fill out this part of the form, you
may strike any wording you do not want.

(6) END-OF-LIFE DECISIONS: I direct that my
health-care providers and others involved in my care provide, withhold, or
withdraw treatment in accordance with the choice I have marked below: (Check
only one box.)

[ ] (a) Choice Not To Prolong Life

I do not want my life to
be prolonged if (i) I have an incurable and irreversible condition that will
result in my death within a relatively short time, (ii) I become unconscious
and, to a reasonable degree of medical certainty, I will not regain
consciousness, or (iii) the likely risks and burdens of treatment would
outweigh the expected benefits, OR

[ ] (b) Choice To Prolong Life

I want my life to be prolonged
as long as possible within the limits of generally accepted health-care
standards.

(7) ARTIFICIAL NUTRITION AND HYDRATION:
Artificial nutrition and hydration must be provided, withheld or withdrawn in
accordance with the choice I have made in paragraph (6) unless I mark the
following box. If I mark this box [ ], artificial nutrition and hydration
must be provided regardless of my condition and regardless of the choice I have
made in paragraph (6).

(8) RELIEF FROM PAIN: If I mark this box [ ],
I direct that treatment to alleviate pain or discomfort should be provided to
me even if it hastens my death.

(9) OTHER WISHES: (If you do not agree with
any of the optional choices above and wish to write your own, or if you wish to
add to the instructions you have given above, you may do so here.) I direct
that:

__________________________________________________________

(Add additional sheets if needed.)

PART 3

DONATION OF
ORGANS AT DEATH

(OPTIONAL)

(10) Upon my death: (mark applicable box)

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

[ ] (b) I give the following organs, tissues, or
parts only

__________________________________________

[ ] (c) My gift is for the following purposes
(strike any of the following you do not want)

(i) Transplant

(ii) Therapy

(iii) Research

(iv) Education

PART 4

PRIMARY
PHYSICIAN

(OPTIONAL)

(11) I designate the following physician as my
primary physician:

__________________________________________________________

(name of physician)

__________________________________________________________

(address) (city) (state) (zip code)

__________________________________________________________

(phone)

OPTIONAL: If the physician I have designated
above is not willing, able, or reasonably available to act as my primary
physician, I designate the following physician as my primary physician:

__________________________________________________________

(name of physician)

__________________________________________________________

(address) (city) (state) (zip code)

__________________________________________________________

(phone)

(12) EFFECT OF COPY: A copy of this form has
the same effect as the original.

(13) SIGNATURES: Sign and date the form here:

_____________________________ _____________________________

(date) (sign your name)

_____________________________ _____________________________

(address) (print your name)

_____________________________

(city) (state)

(14) WITNESSES: This power of attorney will
not be valid for making health-care decisions unless it is either (a) signed
by two qualified adult witnesses who are personally known to you and who are
present when you sign or acknowledge your signature; or (b) acknowledged
before a notary public in the State.

ALTERNATIVE
NO. 1

Witness

I declare under penalty of false swearing
pursuant to section 710-1062, Hawaii Revised Statutes, that the principal is
personally known to me, that the principal signed or acknowledged this power of
attorney in my presence, that the principal appears to be of sound mind and
under no duress, fraud, or undue influence, that I am not the person appointed
as agent by this document, and that I am not a health-care provider, nor an
employee of a health-care provider or facility. I am not related to the
principal by blood, marriage, or adoption, and to the best of my knowledge, I
am not entitled to any part of the estate of the principal upon the death of
the principal under a will now existing or by operation of law.

____________________________ ____________________________

(date) (signature of
witness)

____________________________ ____________________________

(address) (printed name of
witness)

____________________________

(city) (state)

Witness

____________________________ ____________________________

(date) (signature of
witness)

____________________________ ____________________________

(address) (printed name of
witness)

____________________________

(city) (state)

ALTERNATIVE
NO. 2

State of Hawaii

County of ________________

On this _____________ day of _______________, in the
year _______, before me, __________________ (insert name of notary public)
appeared _________________, personally known to me (or proved to me on the
basis of satisfactory evidence) to be the person whose name is subscribed to
this instrument, and acknowledged that he or she executed it.

Notary Seal

____________________________

(Signature of
Notary Public)"

[L 1999, c 169, pt of §1; am L 2004, c 161, §36]

Note

Developing an organ donor registry. L 2008, c 165.

Revision Note

Paragraphs redesignated pursuant to §23G-15(1).