Durable Power of Attorney for Health Care - Hawaii - Edit, Fill, Sign Online

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Hawaii Durable Power of Attorney for Health Care Decisions

Will to Live Form

DESIGNATION OF AGENT

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

designate the following individual as my agent to make health-care decisions for me:

(Name of agent)________________________________________________________________

(address of agent)_______________________________________________________________

(phone number(s) of agent)_______________________________________________________

OPTIONAL: If I revoke my agent’s authority, or if my agent is not willing, able, or reasonably

available to make health-care decisions for me, I designate as my first alternate agent:

First Successor Agent

(successor agent’s name)_________________________________________________________

(successor agent’s address)________________________________________________________

_____________________________________________________________________________

(successor agent’s phone number)__________________________________________________

OPTIONAL: If I revoke the authority of my agent and first alternate agent, or if neither is

willing, able, or reasonably available to make health-care decisions for me, I designate as my

second alternate agent:

Second Successor Agent

(second successor agent’s name)___________________________________________________

(second successor agent’s address)__________________________________________________

______________________________________________________________________________

(second successor agent’s phone number)____________________________________________

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.

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My agent’s authority to make health-care decisions takes effect immediately

INSTRUCTIONS FOR HEALTH CARE:

GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care attorney in fact(s) to make health care

decisions consistent with my general desire for the use of medical treatment that would preserve

my life, as well as for the use of medical treatment that can cure, improve, reduce or prevent

deterioration in, any physical or mental condition.

Food and water are not medical treatment, but basic necessities. I direct my health care

provider(s) and health care attorney in fact to provide me with food and fluids, orally,

intravenously, by tube, or by other means to the full extent necessary both to preserve my life and

to assure me the optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in

order to cause my death.

I direct that the following be provided:

C the administration of medication;

C cardiopulmonary resuscitation (CPR); and

C the performance of all other medical procedures, techniques, and technologies,

including surgery,

–all to the full extent necessary to correct, reverse, or alleviate life-threatening or health

impairing conditions or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of

an unborn or newborn child, who has been subject to an induced abortion. This rejection does

not apply to the use of tissues or organs obtained in the course of the removal of an ectopic

pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner that

causes, contributes to, or hastens that person’s death.

I request and direct that medical treatment and care be provided to me to preserve my life without

discrimination based on my age or physical or mental disability or the “quality” of my life. I

reject any action or omission that is intended to cause or hasten my death.

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I direct my health care provider(s) and health care attorney in fact to follow the policy above,

even if I am judged to be incompetent.

During the time I am incompetent, my attorney in fact, as named below, is authorized to make

medical decisions on my behalf, consistent with the above policy, after consultation with my

health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical

condition, in the following situations with the written special instructions.

WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only a week or less even

if lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even

though death is not imminent I am in the final stage of that terminal condition – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only three months or less,

even if lifesaving treatment or care is provided to me – the following may be withheld or

withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

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C. OTHER SPECIAL CONDITIONS:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and

health care attorney in fact(s) to use all lifesaving procedures for myself with none of the above

special conditions applying if there is a chance that prolonging my life might allow my child to

be born alive. I also direct that lifesaving procedures be used even if I am legally determined to

be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I

specify by writing my signature in the box below, no one is authorized to consent to any

procedure for me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

EFFECT OF COPY

A copy of this form has the same effect as the original.

Signed this ____________________day of ___________________________, 20_______.

(Signature)____________________________________________________________________

(Print Name)___________________________________________________________________

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.

FIRST ALTERNATIVE

I declare under penalty of false swearing pursuant to §710-102, Hawaii Revised Statutes, that the

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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.

First Witness Signature:__________________________________________________________

Date:__________________________________ Address:____________________________

Print Name:____________________________ ____________________________________

I declare under penalty of false swearing pursuant to §710-102, 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.

Second Witness Signature:________________________________________________________

Date:__________________________________ Address:____________________________

Print Name:____________________________ ____________________________________

SECOND ALTERNATIVE

NOTARY PUBLIC

State of Hawaii

County of________________________

On this ________ day of ____________________, 20_____, before me (name of notary public)

______________________________________, personally known to be (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

My commission expires:______________________

Form prepared 2001

*clerical changes made 11/05

Fillable Printable Durable Power of Attorney for Health Care - Hawaii

Fillable Printable Durable Power of Attorney for Health Care - Hawaii

Durable Power of Attorney for Health Care - Hawaii