§327G-14  Optional form.  The followingsample form may be used to create an advance mental health care directive. This sample form may be duplicated, or modified to suit the needs of theperson.  Any written document that contains the substance of the followinginformation may be used in an advance mental health care directive:

"ADVANCEMENTAL HEALTH CARE DIRECTIVE

Explanation

You have the right to give instructions aboutyour own mental health care.  You also have the right to name someone else tomake mental health treatment decisions for you.  This form lets you do eitheror both of these things.  It also lets you express your wishes regarding thedesignation of your health care providers.  If you use this form, you maycomplete or modify all or any part of it.  You are free to use a differentform.

Part 1 of this form is a list of options youmay designate as part of your mental health care and treatment.  For ease ofdesignating specific instructions, mark those options in Part 1.

Part 2 of this form is a power of attorney formental health care.  This lets you name another individual as your agent tomake mental health treatment decisions for you, if you become incapable ofmaking your own decisions, or if you want someone else to make those decisionsfor you now, even though you are still capable of making your own decisions. You may name alternate agents to act for you if your first choice is notwilling, able, or reasonably available to make decisions for you.  Unlessrelated to you, your agent may not be an owner, operator, or employee of ahealth care institution where you are receiving care.

You may allow your agent to make all mentalhealth treatment decisions for you.  However, if you wish to limit theauthority of your agent, you may specify those limitations on the form.  If youdo not 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 mentalcondition;

(2)  Select or discharge health care providers andinstitutions;

(3)  Approve or disapprove diagnostic tests, surgicalprocedures, and programs of medication; and

(4)  Approve or disapprove of electroconvulsivetreatment.

Part 3 of this form lets you give specificinstructions about any aspect of your mental health care and treatment. Choices are provided for you to express your wishes regarding the provision,withholding, or withdrawal of medication and treatment.  Space is provided foryou to add to the choices you have made or for you to write out any additionalwishes.

Part 4 of this form must be completed in orderto activate the advance mental health care directive.  After completing thisform, sign and date the form at the end and have the form witnessed by one orboth of the two methods listed below.  Give a copy of the signed and completedform to your physician, to any other health care providers you may have, to anyhealth care institution at which you are receiving care, and to any mental healthcare agents you have named.  You should talk to the persons you have named asagents to make sure that they understand your wishes and are willing to takethe responsibility.

You have the right to revoke this advancemental health care directive or replace this form at any time, unless otherwisespecified in writing in the advance mental health care directive.

If you are in imminent danger of causing bodilyharm to yourself or others, or have been involuntarily committed to a healthcare institution for mental health treatment, the advance mental health caredirective will not apply.

 

PART 1

CHECKLIST OF MENTALHEALTH CARE OPTIONS

 

NOTE TO PROVIDER:  The following is a checklist ofselections I have made regarding my mental health care and treatment.  Iinclude this statement to express my strong desire for you to acknowledge andabide by my rights, under state and federal laws, to influence decisions aboutthe care I will receive.

(Declarant: Put a check mark in the left-hand column for each section you have completed.)

 

___ Designation of my mental health care agent(s).

___ Authority granted to my agent(s).

___ My preference for a court appointed guardian.

___ My preference of treating facility andalternatives to hospitalization.

___ My preferences about the physicians or othermental health care providers who will treat me if I am hospitalized.

___ My preferences regarding medications.

___ My preferences regarding electroconvulsivetherapy (ECT or shock treatment).

___ My preferences regarding emergency interventions(seclusion, restraint, medications).

___ Consent for experimental drugs or treatments.

___ Who should be notified immediately of myadmission to a facility.

___ Who should be prohibited from visiting me.

___ My preferences for care and temporary custody ofmy children or pets.

___ Other instructions about mental health care andtreatment.

 

PART 2

DURABLE POWER OFATTORNEY FOR MENTAL HEALTH

TREATMENT DECISIONS

 

(1)  DESIGNATION OF AGENT:  I designate the followingindividual as my agent to make mental 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 or if my agentis not willing, able, or reasonably available to make a mental 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 my agent and firstalternate agent or if neither is willing, able, or reasonably available to makea mental health care decision for me, I designate as my second alternate 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 authorized tomake all mental health care treatment decisions for me, including decisions toprovide, withhold, or withdraw medication and treatment, and all other forms ofmental health care, except as I state here:

 

__________________________________________________________

 

__________________________________________________________

 

__________________________________________________________

(Add additional sheets if needed.)

 

(3)  WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE:  Myagent's authority becomes effective when my supervising health care providerwho is a physician and one other physician or licensed psychologist determinethat I am unable to make my own mental health care decisions.

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

(5)  NOMINATION OF GUARDIAN:  If a guardian needs tobe 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 3

INSTRUCTIONS FORMENTAL HEALTH CARE AND TREATMENT

 

If you are satisfied to allow your agent to determinewhat is best for you, you need not fill out this part of the form.  If you dofill out this part of the form, you may strike any wording you do not want.

(6)  My preference of treating facility andalternatives to hospitalization:

(7)  My preferences about the physicians or othermental health care providers who will treat me if I am hospitalized:

(8)  My preferences regarding medications:

(9)  My preferences regarding electroconvulsivetherapy (ECT or shock treatment):

(10)  My preferences regarding emergency interventions(seclusion, restraint, medications):

(11)  Consent for experimental drugs or treatments:

(12)  Who should be notified immediately of myadmission to a facility:

(13)  Who should be prohibited from visiting me:

(14)  My preferences for care and temporary custody ofmy children or pets:

(15)  My preferences about revocation of my advancemental health care directive during a period of incapacity:

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

 

__________________________________________________________

 

__________________________________________________________

 

__________________________________________________________

(Add additional sheets if needed.)

 

PART 4

WITNESSES ANDSIGNATURES

 

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

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

 

_____________________________ _____________________________

(date) (sign your name)

 

_____________________________ _____________________________

(address) (print your name)

 

_____________________________

(city) (state)

 

(19)  WITNESSES:  This power of attorney will not bevalid for making mental 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) acknowledged beforea notary public in the State.

 

AFFIRMATION OFWITNESSES

 

Witness 1

 

I declare under penalty of false swearing pursuant tosection 710-1062, Hawaii Revised Statutes, that the principal is personallyknown to me, that the principal signed or acknowledged this power of attorneyin my presence, that the principal appears to be of sound mind and under noduress, fraud, or undue influence, that I am not the person appointed as agentby this document, and that I am not a health care provider, nor an employee ofa 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 toany part of the estate of the principal upon the death of the principal under awill now existing or by operation of law.

 

_____________________________ _____________________________

(date) (sign your name)

 

_____________________________ _____________________________

(address) (print your name)

 

_____________________________

(city) (state)

 

Witness 2

 

I declare under penalty of false swearing pursuant tosection 710-1062, Hawaii Revised Statutes, that the principal is personallyknown to me, that the principal signed or acknowledged this power of attorneyin my presence, that the principal appears to be of sound mind and under noduress, fraud, or undue influence, that I am not the person appointed as agentby this document, and that I am not a health care provider, nor an employee ofa health care provider or facility.  I am not related to the principal byblood, marriage, or adoption, and to the best of my knowledge, I am notentitled to any part of the estate of the principal upon the death of theprincipal under a will now existing or by operation of law.

 

_____________________________ _____________________________

(date) (sign your name)

 

_____________________________ _____________________________

(address) (print your name)

 

_____________________________

(city) (state)

 

DECLARATION OF NOTARY

 

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 ofsatisfactory evidence) to be the person whose name is subscribed to thisinstrument, and acknowledged that he or she executed it.

 

Notary Seal

 

____________________________

(Signature ofNotary Public)"

 

[L 2004, c 224, pt of §2; am L 2005, c 22, §17]