ADVANCE HEALTH CARE DIRECTIVE FORM

Your Name: Last First Middle initial

Street Address City State Zip

Part 1: INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE

The following statements only apply

• 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.)

A. 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.

B. A

RTIFICIAL 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.

C. R

ELIEF 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.

D. E

THICAL, RELIGIOUS, OR SPIRITUAL INSTRUCTIONS (OPTIONAL)

Is there a church, temple, spiritual group or a special person from whom you wish to receive spiritual care?

Name: Phone

Street Address City State Zip

E. DO YOU WANT HOSPICE CARE, IF APPROPRIATE? ____ YES ____ NO

(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.)

F. P

RIMARY CARE PHYSICIAN

Name: Phone

G. OTHER WISHES:

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:

■■ Doctor copy ■■ Family Copy ■■ Agent Copy ■■ www.myhealthdirective.com

ADVANCE HEALTH CARE DIRECTIVE FORM

Date:

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: W

ITNESSES

Witness #1 Print Name Witness Signature Date

Address City State Zip Code

Witness #2 Print Name Witness Signature Date

Address City State Zip Code

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.

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.

This brochure provides general information and does not constitute legal advice and may

not apply to your individual situation.

C HECKLIST

____ Talk with your spouse, adult children, family, friends, spiritual

advisors, and doctors about what would be important to you.

____ Ask someone you trust and can count on to be your health care

agent. Discuss your wishes with this person. Select an alternate health

care agent in case your agent is unable to serve.

____ Complete the enclosed optional Advance Health Care Directive

or make a document of your own. You can add more pages if needed.

____ Have two qualified witnesses or a notary public witness your

signature.

____ Inform family, friends, and doctors that you have an Advance

Health Care Directive and that you expect them to honor your wishes.

Keep them informed about your current wishes.

____ Give copies of the Advance Directive to your health care agent, health

care providers, family, close friends, spiritual advisors, and any other indi-

viduals who might be involved in your care. Register your Advance

Directive free of charge in Hawaii's own Document Bank at

www.myhealthdirective.com.

____ Place copies in your medical files.

____ 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.

Developed by the Executive Office on Aging, State of Hawai‘i.

Checklist originally developed by UH Elder Law Program.

Revised April 2002.

FOR FUTURE

HEALTH CARE

ADVANCE

DIRECTIVE

YOUR

2 3

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.

Notary Public

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

Oahu: UH Elder Law Program 956-6544

www.hawaii.edu/uhelp

Big Island: Legal Aid Society (Hilo) 808-934-0678

(Kona) 808-329-8331

For further information contact:

Kokua Mau (Continuous Care) website at

www.kokuamau.org.

Kokua Mau Speaker’s Bureau: (800) 474-2113. Churches, Temples or

Spiritual Groups can ask about the Complete Life Course.

WHY DO

I NEED AN ADVANCE DIRECTIVE?

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

IS HONORED

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.

tive.com or call 587-4781.