§327E-16  Optional form.  The followingsample form may be used to create an advance health-care directive.  This formmay 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 thefollowing form.

 

"ADVANCEHEALTH-CARE DIRECTIVE

 

Explanation

 

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

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

Unless the form you sign limits the authorityof your agent, your agent may make all health-care decisions for you.  Thisform has a place for you to limit the authority of your agent.  You need not limitthe authority of your agent if you wish to rely on your agent for allhealth-care decisions that may have to be made.  If you choose not to limit theauthority 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 ormental condition;

(2)  Select or discharge health-care providers andinstitutions;

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

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

Part 2 of this form lets you give specificinstructions about any aspect of your health care.  Choices are provided foryou to express your wishes regarding the provision, withholding, or withdrawalof treatment to keep you alive, including the provision of artificial nutritionand hydration, as well as the provision of pain relief medication.  Space isprovided for you to add to the choices you have made or for you to write outany additional wishes.

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

After completing this form, sign and date theform at the end and have the form witnessed by one of the two alternativemethods listed below.  Give a copy of the signed and completed form to yourphysician, to any other health-care providers you may have, to any health-careinstitution at which you are receiving care, and to any health-care agents youhave named.  You should talk to the person you have named as agent to make surethat he or she understands your wishes and is willing to take theresponsibility.

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

 

PART 1

DURABLE POWEROF ATTORNEY FOR HEALTH-CARE DECISIONS

 

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

 

__________________________________________________________

(name of individual you choose asagent)

 

__________________________________________________________

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

 

__________________________________________________________

(home phone)  (work phone)

 

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

 

__________________________________________________________

(name of individual you choose as firstalternate agent)

 

__________________________________________________________

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

 

__________________________________________________________

(home phone)  (work phone)

 

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

 

__________________________________________________________

(name of individual you choose as secondalternate agent)

 

__________________________________________________________

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

 

__________________________________________________________

(home phone)  (work phone)

 

(2)  AGENT'S AUTHORITY:  My agent is authorizedto make all health-care decisions for me, including decisions to provide,withhold, or withdraw artificial nutrition and hydration, and all other formsof 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 determinesthat I am unable to make my own health-care decisions unless I mark thefollowing box.  If I mark this box [  ], my agent's authority to makehealth-care decisions for me takes effect immediately.

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

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

 

PART 2

INSTRUCTIONSFOR HEALTH CARE

 

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

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

[  ] (a)  Choice Not To Prolong Life

I do not want my life tobe prolonged if (i) I have an incurable and irreversible condition that willresult in my death within a relatively short time, (ii) I become unconsciousand, to a reasonable degree of medical certainty, I will not regainconsciousness, or (iii) the likely risks and burdens of treatment wouldoutweigh the expected benefits, OR

[  ] (b)  Choice To Prolong Life

I want my life to be prolongedas long as possible within the limits of generally accepted health-carestandards.

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

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

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

 

__________________________________________________________

 

__________________________________________________________

(Add additional sheets if needed.)

 

PART 3

DONATION OFORGANS AT DEATH

(OPTIONAL)

 

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

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

OR

[  ] (b)  I give the following organs, tissues, orparts 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

PRIMARYPHYSICIAN

(OPTIONAL)

 

(11)  I designate the following physician as myprimary physician:

 

__________________________________________________________

(name of physician)

 

__________________________________________________________

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

 

__________________________________________________________

(phone)

 

OPTIONAL:  If the physician I have designatedabove is not willing, able, or reasonably available to act as my primaryphysician, 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 hasthe 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 willnot be valid for making health-care decisions unless it is either (a)  signedby two qualified adult witnesses who are personally known to you and who arepresent when you sign or acknowledge your signature; or (b)  acknowledgedbefore a notary public in the State.

 

ALTERNATIVENO. 1

 

Witness

I declare under penalty of false swearingpursuant to section 710-1062, Hawaii Revised Statutes, that the principal ispersonally known to me, that the principal signed or acknowledged this power ofattorney in my presence, that the principal appears to be of sound mind andunder no duress, fraud, or undue influence, that I am not the person appointedas agent by this document, and that I am not a health-care provider, nor anemployee of a health-care provider or facility.  I am not related to theprincipal by blood, marriage, or adoption, and to the best of my knowledge, Iam not entitled to any part of the estate of the principal upon the death ofthe principal under a will now existing or by operation of law.

 

____________________________ ____________________________

(date) (signature ofwitness)

 

____________________________ ____________________________

(address) (printed name ofwitness)

 

____________________________

(city) (state)

 

Witness

I declare under penalty of false swearingpursuant to section 710-1062, Hawaii Revised Statutes, that the principal ispersonally known to me, that the principal signed or acknowledged this power ofattorney in my presence, that the principal appears to be of sound mind andunder no duress, fraud, or undue influence, that I am not the person appointedas agent by this document, and that I am not a health-care provider, nor anemployee of a health-care provider or facility.

 

____________________________ ____________________________

(date) (signature ofwitness)

 

____________________________ ____________________________

(address) (printed name ofwitness)

 

____________________________

(city) (state)

 

ALTERNATIVENO. 2

 

State of Hawaii

County of ________________

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

 

Notary Seal

 

____________________________

(Signature ofNotary 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).