$23.95

Add to cart

Hawaii t. Notary Seal ____________________________ (Signature of Notary Public) -7- _______________, 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 i On this _____________ day of ____________________, in the year _______, before me, _____________________________________________ (insert name of notary public) appeared ____________________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ ALTERNATIVE NO. 2 State of Hawaii County of ________________n 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. Date: ____________________________ -6- _______________________ 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 perso_ Address: ______________________________________ Witness I declare under penalty of false swearing pursuant to section 710-1062, Hawaii Revised Statutes, that the principal is personally known to me,al under a will now existing or by operation of law. Date: ____________________________ _____________________________________________ (Witness Signature) Print Name: __________________________________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 principnd 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 62, 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 mient 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 710-104) 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 pres) ____________________________ (sign your name) -5- __________________________________ (address) __________________________________ (city) (state) ____________________________ (print your name) (1__________________________ (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____________ (name of physician) _____________________________________________________________________________ (Address) (city) (state) (zip code) ___________________________________________________ot willing, able, or reasonably available to act as my primary physician, I designate the following physician as my primary physician: _____________________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (phone) OPTIONAL: If the physician I have designated above is nollowing physician as my primary physician: _____________________________________________________________________________ (name of physician) _________________________________________________________is for the following purposes (strike any of the following you do not want) (i) Transplant -4- (ii) Therapy (iii) Research (iv) Education PART 4 PRIMARY PHYSICIAN (OPTIONAL) (11) I designate the fI give any needed organs, tissues, or parts, OR (b) I give the following organs, tissues, or parts only _________________________________________ _________________________________________ (c) My gift ______________________________________________________________________ (Add additional sheets if needed.) PART 3 DONATION OF ORGANS AT DEATH (OPTIONAL) (10) Upon my death: (mark applicable box) (a) rite your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that: _____________________________________________________________________________ _______ 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 wf 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 , IFICIAL 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. Itreatment 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) ARTI in my death within a relatively short time, (ii) I become -3- unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the likely risks and burdens of e 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 resultform, 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 accordancEALTH 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 ted 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 Hmy agent shall consider my personal values to the extent known to my agent. (5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I nominate the agent designamy 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 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 o 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:________________________ (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 t____________________________________________________________________ _____________________________________________________________________________ _____________________________________________________-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: _________city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) -2- (2) AGENT'S AUTHORITY: My agent is authorized to make all health___________________________________________________ (name of individual you choose as second alternate agent) _____________________________________________________________________________ (address) (f 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: ______________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) OPTIONAL: If I revoke the authority oagent: _____________________________________________________________________________ (name of individual you choose as first alternate agent) _________________________________________________________e 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 ) _____________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (homsignate the following individual as my agent to make health-care decisions for me: _____________________________________________________________________________ (name of individual you choose as agentonsibility. 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 de 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 resp 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 -1- which you arehis 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 twoal 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 t 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 artificite; 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 anyr 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 resuscitaimit 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 oou 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 l 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 yrnate 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 ofalth-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 alte 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 hecare 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 mayd at findlegalforms.com -6- 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-ny possible tax consequences arising out of this document should be discussed with a tax professional. -5- [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use foun signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Ar tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using ores have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/o the person, or a completely different form may be used that contains the substance of the following form. (form enclosed below) [_] These forms are provided "as is" and no implied or express warrantiof the conflict. [§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 in the decree or in a power of attorney for health care. (e) An advance health-care directive that conflicts with an earlier advance health-care directive revokes the earlier directive to the extent at which the patient is receiving care. (d) A decree of annulment, divorce, dissolution of marriage, or legal separation revokes a previous designation of a spouse as agent unless otherwise specifiedprovider, agent, guardian, or surrogate who is informed of a revocation shall promptly communicate the fact of the revocation to the supervising health-care provider and to any health-care institutionn individual may revoke all or part of an advance health-care directive, other than the designation of an agent, at any time and in any manner that communicates an intent to revoke. (c) A health-care 4] Revocation of advance health-care directive. (a) An individual may revoke the designation of an agent only by a signed writing or by personally informing the supervising health-care provider. (b) Advance health-care directive shall be valid for purposes of this chapter if it complies with this chapter, or if it was executed in compliance with the laws of the state where it was executed. [§327E-y an agent for a principal shall be effective without judicial approval. (i) A written advance health-care directive may include the individual's nomination of a guardian of the person. -4- (j) An ahe principal's best interest. In determining the principal's best interest, the agent shall consider the principal's personal values to the extent known to the agent. (h) A health-care decision made b with the principal's individual instructions, if any, and other wishes to the extent known to the agent. Otherwise, the agent shall make the decision in accordance with the agent's determination of t that another condition exists that affects an individual instruction or the authority of an agent, shall be made by the primary physician. (g) An agent shall make a health-care decision in accordancetermination that the principal has recovered capacity. (f) Unless otherwise specified in a written advance health-care directive, a determination that an individual lacks or has recovered capacity, ortherwise specified in a power of attorney for health care, the authority of an agent becomes effective only upon a determination that the principal lacks capacity, and ceases to be effective upon a den the principal's death under any will or codicil thereto of the principal existing at the time of execution of the power of attorney for health care or by operation of law then existing. (e) Unless oor a power of attorney for health care shall be someone who is neither: (1) Related to the principal by blood, marriage, or adoption; nor (2) Entitled to any portion of the estate of the principal upor of attorney for health care shall not be: (1) A health-care provider; (2) An employee of a health-care provider or facility; or (3) The agent. (d) At least one of the individuals used as a witness fhe instrument by the principal or the principal's acknowledgment of the signature of the instrument; or (2) Acknowledged before a notary public at any place within this State. (c) A witness for a powein the date of its execution, be signed by the principal, and be witnessed by one of the following methods: -3- (1) Signed by at least two individuals, each of whom witnessed either the signing of tcipal by blood, marriage, or adoption, an agent may not be an owner, operator, or employee of the health-care institution at which the principal is receiving care. The power shall be in writing, contaon the principal could have made while having capacity. The power remains in effect notwithstanding the principal's later incapacity and may include individual instructions. Unless related to the printed to take effect only if a specified condition arises. (b) An adult or emancipated minor may execute a power of attorney for health care, which may authorize the agent to make any health-care decisiion for the patient. [§327E-3] Advance health-care directives. (a) An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limi undertaken primary responsibility for an individual's health care. "Surrogate" means an individual, other than a patient's agent or guardian, authorized under this chapter to make a health-care decisect to the jurisdiction of the United States. "Supervising health-care provider" means the primary physician or the physician's designee, or the health-care provider or the provider's designee who hasidering the urgency of the patient's health care needs. "State" means a state of the United States, the District of Columbia, the Commonwealth of Puerto Rico, or a territory or insular possession subjsonably available" means able to be contacted with a level of diligence appropriate to the seriousness and urgency of a patient's health care needs, and willing and able to act in a timely manner consmary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility. "Reant to make health-care decisions for the individual granting the power. "Primary physician" means a physician designated by an individual or the individual's agent, guardian, or surrogate, to have pri legal or commercial entity. "Physician" means an individual authorized to practice medicine or osteopathy under chapter 453 or 460. "Power of attorney for health care" means the designation of an age -2- "Person" means an individual, corporation, business trust, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency, or instrumentality, or any otherent of the patient, an adult sibling or adult grandchild of the patient, or any adult who has exhibited special care and concern for the patient and who is familiar with the patient's personal values.tion concerning a health-care decision for the individual. "Interested persons" means the patient's spouse, unless legally separated or estranged, a reciprocal beneficiary, any adult child, either parnsed, certified, or otherwise authorized or permitted by law to provide health care in the ordinary course of business or practice of a profession. "Individual instruction" means an individual's direcitution, facility, or agency licensed, certified, or otherwise authorized or permitted by law to provide health care in the ordinary course of business. "Health-care provider" means an individual liceutions. "Health-care decision" means a decision made by an individual or the individual's agent, guardian, or surrogate, regarding the individual's health care. "Health-care institution" means an instition and hydration; provided that withholding or withdrawing artificial nutrition or hydration is in accord with generally accepted health care standards applicable to health-care providers or institutions; (2) Approval or disapproval of diagnostic tests, surgical procedures, programs of medication, and orders not to resuscitate; and (3) Direction to provide, withhold, or withdraw artificial nutrre, treatment, service, or procedure to maintain, diagnose, or otherwise affect an individual's physical or mental condition, including: (1) Selection and discharge of health-care providers and institears of age who is totally selfsupporting. "Guardian" means a judicially appointed guardian or conservator having authority to make a health-care decision for an individual. "Health care" means any ca ability to understand the significant benefits, risks, and alternatives to proposed health care and to make and communicate a health-care decision. "Emancipated minor" means a person under eighteen ys beliefs and basic values of the individual receiving treatment, to the extent that these may assist the surrogate decision-maker in determining benefits and burdens. "Capacity" means an individual'st; (5) The prognosis of the patient for recovery, with and without the treatment; (6) The risks, side effects, and benefits of the treatment or the withholding of treatment; and -1- (7) The religioul's medical condition, the treatment, or the withholding or withdrawal of treatment, results in a severe and continuing impairment; (4) The effect of the treatment on the life expectancy of the patiennctions of the patient; (2) The degree of physical pain or discomfort caused to the individual by the treatment or the withholding or withdrawal of the treatment; (3) The degree to which the individuadividual resulting from a treatment outweigh the burdens to the individual resulting from that treatment and shall include: (1) The effect of the treatment on the physical, emotional, and cognitive fue. "Agent" means an individual designated in a power of attorney for health care to make a health-care decision for the individual granting the power. "Best interest" means that the benefits to the inForm. [§327E-2] Definitions. Whenever used in this chapter, unless the context otherwise requires: "Advance health-care directive" means an individual instruction or a power of attorney for health carWill) is based on Volume 6 Chapter 327E Section 327E-2 et. Seq. of the Hawaii Statutes. The following are useful excerpts from the Hawaii Statutes relating to the Hawaii Advance Health Care Directive Living Will); (2) Hawaii Advance Health Care Directive (Power of Attorney for Health Care and Living Will) Form This Hawaii Advance Health Care Directive (Power of Attorney for Health Care and Living Information and Instructions Hawaii Advance Health Care Directive This package contains (1) Information and Instruction for Hawaii Advance Health Care Directive (Power of Attorney for Health Care and Hawaii