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Hawaii dence) 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) -5- ________________________________________ (insert name of notary public) appeared _____________________________________________, personally known to me (or proved to me on the basis of satisfactory eviress: ______________________________________ -4- ALTERNATIVE NO. 2 State of Hawaii County of ________________ On this _____________ day of ____________________, in the year _______, before me, _____employee of a health-care provider or facility. Date: ____________________________ _____________________________________________ (Witness Signature) Print Name: ___________________________________ Addhe 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 se 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 t_____________________________________________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Witness I declare under penalty of falbest 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. Date: ____________________________ 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 cipal 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 aslic 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 prin-3____________________________ (sign your name) ____________________________ (print your name) and who are present when you sign or acknowledge your signature; or (b) acknowledged before a notary pub(city) (state) (9) 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 the same effect as the original. (8) SIGNATURES: Sign and date the form here: __________________________________ (date) __________________________________ (address) __________________________________ _______________________________ (Address) (city) (state) (zip code) _____________________________________________________________________________ (phone) (7) EFFECT OF COPY: A copy of this form has gnate the following physician as my primary physician: _____________________________________________________________________________ (name of physician) _____________________________________________________________________________________________________ (phone) OPTIONAL: If the physician I have designated above is not willing, able, or reasonably available to act as my primary physician, I desi_________________________________________ (name of physician) _____________________________________________________________________________ (address) (city) (state) (zip code) ______________________) Transplant (ii) Therapy (iii) Research (iv) Education -2- PART 3 PRIMARY PHYSICIAN (OPTIONAL) (6) I designate the following physician as my primary physician: ____________________________________s, tissues, or parts only _________________________________________ _________________________________________ (c) My gift is for the following purposes (strike any of the following you do not want) (idditional sheets if needed.) PART 2 DONATION OF ORGANS AT DEATH (OPTIONAL) (5) Upon my death: (mark applicable box) (a) I give any needed organs, tissues, or parts, OR (b) I give the following organ, you may do so here.) I direct that: _____________________________________________________________________________ _____________________________________________________________________________ (Add ame even if it hastens my death. (4) 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 aboveess of my condition and regardless of the choice I have made in paragraph (1). (3) RELIEF FROM PAIN: If I mark this box , I direct that treatment to alleviate pain or discomfort should be provided to ovided, withheld or withdrawn in accordance with the choice I have made in paragraph (1) unless I mark the following box. If I mark this box artificial nutrition and hydration must be provided regardl I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards. (2) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and hydration must be pr 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 -1- 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 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 Tois Living Will or replace this form at any time. PART 1 INSTRUCTIONS FOR HEALTH CARE If you do fill out this part of the form, you may strike any wording you do not want. (1) END-OF-LIFE DECISIONS: Ian, to any other health-care providers you may have and to any health-care institution at which you are receiving care and to any health-care agents you may have named. You have the right to revoke thter completing this form, sign and date the form at the end and have the form witnessed by one of the two alternative methods listed below. Give a copy of the signed and completed form to your physicied for you to add to the choices you have made or for you to write out any additional wishes. Part 3 of this form lets you designate a physician to have primary responsibility for your health care. Afprovision, withholding, or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief medication. Space is provid. You are free to use a different form. Part 1 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the ructions about your own health care. It also lets you express your wishes regarding the designation of your health-care provider. If you use this form, you may complete or modify all or any part of itubject to the Disclaimers and Terms of Use found at findlegalforms.com -3- LIVING WILL Explanation You have the right to give instructions about your own health care. This form lets you to give instenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is sut consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whnot intended and are not a substitute for legal and/or 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 withoe provided "as is" and no implied or express warranties 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 orney 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 of the conflict. [_] These forms ar -2- (d) A decree of annulment, divorce, dissolution of marriage, or legal separation revokes a previous designation of a spouse as agent unless otherwise specified in the decree or in a power of attho is informed of a revocation shall promptly communicate the fact of the revocation to the supervising health-care provider and to any health-care institution at which the patient is receiving care. 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 provider, agent, guardian, or surrogate wctive. (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) An individual may revoke all or part of anid 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-4] Revocation of advance health-care dire effective without judicial approval. (i) A written advance health-care directive may include the individual's nomination of a guardian of the person. (j) An advance health-care directive shall be valtermining 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 by an agent for a principal shall bestructions, 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 the principal's best interest. In de 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 accordance with the principal's individual inrecovered capacity. (f) Unless otherwise specified in a written advance health-care directive, a determination that an individual lacks or has recovered capacity, or that another condition exists thattorney 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 determination that the principal has ill 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 otherwise specified in a power of atall be someone who is neither: (1) Related to the principal by blood, marriage, or adoption; nor -1- (2) Entitled to any portion of the estate of the principal upon the principal's death under any we: (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 for a power of attorney for health care shncipal'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 power of attorney for health care shall not bgned by the principal, and be witnessed by one of the following methods: (1) Signed by at least two individuals, each of whom witnessed either the signing of the instrument by the principal or the prion, 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, contain the date of its execution, be siile having capacity. The power remains in effect notwithstanding the principal's later incapacity and may include individual instructions. Unless related to the principal by blood, marriage, or adoptiied 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 decision the principal could have made whnce 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 limited to take effect only if a speciflume 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 Form. [§327E-3] AdvaInformation and Instructions Hawaii Living Will This package contains (1) Information and Instruction for Hawaii Living Will; (2) Hawaii Living Will Form This Hawaii Living Will is based in part on Vo Hawaii