if I am close to death and life support would only postpone the moment of my death OR
if I am in an unconscious state such as an irreversible coma or a persistent vegetative state and it is unlikely that I will ever become conscious OR
if I have brain damage or a brain disease that makes me permanently unable to make and communicate health-care deci- sions about myself.
(INITIAL ONLY ONE (1) CHOICE IN EACH SECTION and CROSS OUT ALL THAT DO NOT APPLY.)
CHOICE TO PROLONG OR NOT TO PROLONG LIFE
YES, I do want to have my life prolonged as long as possible within the limits of generally accepted health-care standards that apply to my condition.
NO, I do not want my life prolonged.
ARTIFICIAL NUTRITION AND HYDRATION (FOOD AND FLUIDS) BY TUBE INTO STOMACH OR VEIN
YES, I do want artificial nutrition and hydration.
NO, I do not want artificial nutrition and hydration.
RELIEF FROM PAIN
YES, I do want treatment to relieve my pain or discomfort.
NO, I do not want treatment to relieve my pain or discomfort.
ETHICAL, RELIGIOUS, OR SPIRITUAL INSTRUCTIONS (OPTIONAL)
Is there a church, temple, spiritual group or a special person from whom you wish to receive spiritual care?
E. DO YOU WANT HOSPICE CARE, IF APPROPRIATE?
(Hospice provides physical, psychosocial, emotional, and spiritual support and counseling for the patient and his/her family. Hospice is available in home, hospital, hospice-unit, and nursing home settings.)
PRIMARY CARE PHYSICIAN
If you do not agree with any of the choices above or wish to add other instructions, including body and organ donation, you may add pages. If you are or could become pregnant, consult your doctor, and consider adding special instructions suspending or adding provisions. Remember to sign, date, witness or notarize additional pages. File a copy with:
PART 2: HEALTH-CARE POWER OF ATTORNEY AGENT’S AUTHORITY AND OBLIGATION
My agent shall make health-care decisions for me in accordance with my best interests and wishes so far as they are known. In determining my best interest, my agent shall consider my personal values. If a guardian of my person needs to be appoint- ed for me by a court, I nominate my agent. I designate the following individual as my agent. He/she may make all health- care decisions for me if I am unable or unwilling to make them for myself unless I direct otherwise:
Name of Agent (Spouse, adult child, friend or other trusted person) Relationship
Street Address City State Zip Home Phone Work Phone E-mail
If my agent is not available, I designate the following person as my alternative agent:
Name of Alternate Agent (Spouse, adult child, friend or other trusted person) Relationship
Street Address City State Zip Home Phone Work Phone E-mail
My agent may make all health-care decisions for me. OR
My agent may make all health-care decisions for me except:
My agent’s authority becomes effective when my primary physician determines that I am unable to make health-care decisions.OR
My agent’s authority to make health-care decisions for me takes effect immediately.
YOUR NAME: Print Your Full Name Your Signature Date
WITNESSES: CHOOSE EITHER OPTION 1 OR 2, NOT BOTH.
Important: Witnesses cannot be your health-care agent, a health-care provider or an employee of a health-care facility. One witness cannot be a relative or have inheritance rights.
OPTION 1: WITNESSES
Witness #1 Print Name
Witness #2 Print Name
OPTION 2: Notary Public
State of Hawai‘i, (County)
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 of satis- factory evidence) to be the person whose name is subscribed to this instrument and acknowledged that he or she executed it.
My Commission Expires:
A copy has the same effect as the original.
Developed by the Executive Office on Aging, State of Hawai‘i – Revised September 2003.
Keep a copy in any easy to find place in your home. (Not in a safe deposit box!!) You could leave a note on the refrigerator to tell people where your important documents are so they can be found when they are needed.
You may designate “Advance Directive” on your driver’s license or state identification card to indicate that you have completed an Advance Directive and wish it to be honored. Hawaii drivers’ license stations do not file Advanced Directives.
Review your Advance Directive regularly. In case you make changes, inform people, create a new document, and replace the old one.
This brochure provides general information and does not constitute legal advice and may not apply to your individual situation.
Developed by the Executive Office on Aging, State of Hawai‘i. Checklist originally developed by UH Elder Law Program.
Revised April 2002.
FUTURE EALTH CARE
It is a gift to family members and friends
so that they won’t have to guess what you want if you no longer can speak for yourself.
Medical technology has given us many new options for sustaining life. This makes it important for you to discuss what kind of care you want before serious illness or accident occurs.
Now is the time to talk about these important issues while you can still make your own decisions and have time to talk about them with others.
If you don’t have an Advance Directive and even one person interested in your care disagrees, your doctor may not honor your wishes for end-of-life care.
The Advance Directive takes the place of the former living will document and gives you more options. Review your existing forms to decide if an Advance Health Care Directive will better reflect your wishes.
WHAT DO I PUT IN MY ADVANCE DIRECTIVE?
THE KIND OF HEALTH TREATMENT YOU WANT OR DON’T WANT.
You can say whether or not you want to be kept alive by machines that breathe for you or feed you even if there is no hope you will get better.
YOUR WISHES FOR COMFORT CARE.
You can indicate whether you want medicine for pain or where you want to spend your last days. You can also give spiritual, ethical, and religious intructions.
THE PERSON OR “AGENT” YOU WANT TO MAKE DECISIONS FOR YOU WHEN YOU CANNOT.
This agent does not have to be an attorney. Unless you limit your agent’s authority, your agent has the right to accept or refuse any kind of medical care and testing, discharge or select doctors, and see all medical records.
HOW CAN I ENSURE MY ADVANCE DIRECTIVE
Share copies and talk with people who will be involved in your care. Ask your doctor to insert your Advance Directive into your medical records. Register your Advance Directive free of charge at www.MyHealthDirec- tive.com or call 587-4781.
INSTRUCTIONS FOR ADVANCE HEALTH CARE
DIRECTIVE (in accordance with the Uniform Health Care Decisions Act, 1999)
Complete Part 1 and 2 on the enclosed form. You may add pages and make any changes you wish. You do not need an attorney to complete this form. If you need more help, consult the phone numbers included in this brochure. Complete the check list on the back page.
PART 1 – INDIVIDUAL INSTRUCTION
Give instructions to your doctor and others about any aspect of your health care. You will be given choices. Check only one box in each category and cross out all which do not apply.
PART 2 – HEALTH CARE POWER OF ATTORNEY, YOUR AGENT
Select one or more persons to be your agent and make health care deci- sions if you are unable. The person you appoint can be a spouse, adult child, friend, or any other trusted person. Your agent cannot be an owner or employee of a health care facility where you are receiving care unless they are related to you.
Ask two witnesses to sign and date the form
Both must be people you know. They cannot be health care providers, employees of a health care facility, or the person you choose as an agent. One person cannot be related to you or have inheritance rights.
If you do not have 2 witnesses, your Advance Directive must be notarized.
You have the right to revoke or change your Advance Directive at any time orally or in writing. Be sure to tell your agent and doctor.
WHO CAN HELP ME COMPLETE MY ADVANCE DIRECTIVE?
Kauai: Seniors Law Program 808-246-0573
Maui, Molokai, Lanai: Legal Aid Society 808-242-0724