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Hawaii Advance Directive Form

A Hawaii advance directive is a form that allows someone to express instructions for medical and end-of-life care and to designate someone to make medical decisions on their behalf. The directive covers such matters as prolonging life, using a feeding or breathing tube, pain relief, and hospice. This document becomes useful in case of mental incapacitation or serious illness.

Signing Requirements (Haw. Rev. Stat. § 327E-3) – Two (2) witnesses or a notary public. A witness should not be a healthcare provider, and one must not be related to the declarant or entitled to any portion of the declarant’s estate.

Statutory Form

ADVANCE HEALTH-CARE DIRECTIVE

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]
(name of individual you choose as agent)
(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
[EXCEPTIONS]
(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:

[OTHER WISHES]

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

_________________________________ [DAY] day of [MONTH], 20[XX]

(11) 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.

_________________________________ [DAY] day of [MONTH], 20[XX]

_________________________________ [DAY] day of [MONTH], 20[XX]

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.

_________________________________ [DAY] day of [MONTH], 20[XX]

_________________________________ [DAY] day of [MONTH], 20[XX]