Hawaii Medical Power of Attorney Form

In the case of wanting to assign another person to make medical decisions on your behalf in the State of Hawaii, the following form has to be completed and submitted.

Extracted Text for Proper Search

Some states use the terms “attorney in fact,” “surrogate,” “designee,” and “representative” instead of “agent.”  They 1are synonymous for purposes of these suggestions.-i-SUGGESTIONSFOR PREPARING WILL TO LIVEDURABLE POWER OF ATTORNEY (Please read the document itself before reading this.  It will help you better understand the suggestions.)YOU ARE NOT REQUIRED TO FILL OUT ANY PART OF THIS "WILL TO LIVE" ORANY OTHER DOCUMENT SUCH AS A LIVING WILL OR DURABLE POWER OFATTORNEY FOR HEALTH CARE.  NO ONE MAY FORCE YOU TO SIGN THISDOCUMENT OR ANY OTHER OF ITS KIND. The Will to Live form starts from the principle that the presumption should be for life.  Ifyou sign it without writing any "SPECIAL CONDITIONS," you are giving directions to yourhealth care provider(s) and health care agent to do their best to preserve your life. 1 Some people may wish to continue certain types of medical treatment when they areterminally ill and in the final stages of life.  Others may not. If you wish to refuse some specific medical treatment, the Will to Live form providesspace to do so ("SPECIAL CONDITIONS").  You may make special conditions for yourtreatment when your death is imminent, meaning you will live no more than a week even if givenall available medical treatment; or when you are incurably terminally ill, meaning you will liveno more than three months even if given all available medical treatment.  There is also space foryou to write down special conditions for circumstances you describe yourself. The important thing for you to remember if you choose to fill out any part of the"SPECIAL CONDITIONS" sections of the Will to Live is that you must be very specific inlisting what treatments you do not want.  Some examples of how to be specific will be givenshortly, or you may ask your physician what types of treatment might be expected in yourspecific case. Why is it important to be specific?  Because, given the pro-euthanasia views widespreadin society and particularly among many (not all) health care providers, there is great danger that avague description of what you do not want will be misunderstood or distorted so as to deny youtreatment that you do want. Many in the medical profession as well as in the courts are now so committed to thequality of life ethic that they take as a given that patients with severe disabilities are better offdead and would prefer not to receive either life-saving measures or nutrition and hydration.  So

-ii-pervasive is this "consensus" that it is accurate to say that in practice it is no longer true that the"presumption is for life" but rather for death.  In other words, instead of assuming that a nowincompetent patient would want to receive treatment and care in the absence of clear evidence tothe contrary, the assumption has virtually become that since any "reasonable" person would wantto exercise a "right to die," treatment and care should be withheld or withdrawn unless there isevidence to the contrary.  The Will to Live is intended to maximize the chance of providing thatevidence. It is important to remember that you are writing a legal document, not holding aconversation, and not writing a moral textbook.  The language you or a religious or moral leadermight use in discussing what is and is not moral to refuse is, from a legal standpoint, often muchtoo vague.  Therefore, it is subject to misunderstanding or deliberate abuse. The person you appoint as your health care agent may understand general terms in thesame way you do.  But remember that the person you appoint may die, or become incapacitated,or simply be unavailable when decisions must be made about your health care.  If any of thesehappens, a court might appoint someone else you don't know in that person's place.  Alsoremember that since the agent has to follow the instructions you write in this form, a health careprovider could try to persuade a court that the agent isn't really following your wishes.  A courtcould overrule your agent's insistence on treatment in cases in which the court interprets anyvague language you put in your "Will to Live" less protectively than you meant it. So, for example, do not simply say you don't want "extraordinary treatment."  Whateverthe value of that language in moral discussions, there is so much debate over what it meanslegally that it could be interpreted very broadly by a doctor or a court.  For instance, it might beinterpreted to require starving you to death when you have a disability, even if you are in nodanger of death if you are fed. For the same reason, do not use language rejecting treatment which has a phrase like"excessive pain, expense or other excessive burden."  Doctors and courts may have a verydifferent definition of what is "excessive" or a "burden" than you do.  Do not use language thatrejects treatment that "does not offer a reasonable hope of benefit."  "Benefit" is a legally vagueterm. If you had a significant disability, a health care provider or court might think you wouldwant no medical treatment at all, since many doctors and judges unfortunately believe there is no"benefit" to life with a severe disability. What sort of language is specific enough if you wish to write exclusions?  Here are someexamples of things you might--or might not--want to list under one or more of the "SpecialConditions" described on the form.  Remember that any of these will prevent treatment ONLYunder the circumstances--such as when death is imminent--described in the "Special Condition"you list it under.  (The examples are not meant to be all inclusive--just samples of the type ofthing you might want to write.)

-iii- "Cardiopulmonary resuscitation (CPR)."  (If you would like CPR in some but not allcircumstances when you are terminally ill, you should try to be still more specific: for example,you might write "CPR if cardiopulmonary arrest has been caused by my terminal illness or acomplication of it."  This would mean that you would still get CPR if, for example, you were thevictim of smoke inhalation in a fire.)  "Organ transplants."  (Again, you could be still morespecific, rejecting, for example, just a "heart transplant.") "Surgery that would not cure me, would not improve either my mental or my physicalcondition, would not make me more comfortable, and would not help me to have less pain, butwould only keep me alive longer." "A treatment that will itself cause me severe, intractable, and long-lasting pain but willnot cure me."Pain Relief Under the "General Presumption for Life," of your Will to Live, you will be givenmedication necessary to control any pain you may have "as long as the medication is not used inorder to cause my death."   This means that you may be given pain medication that has thesecondary, but unintended, effect of shortening your life.  If this is not your wish, you may wantto write something like one of the following under the third set of "Special Conditions" (thesection for conditions you describe yourself): "I would like medication to relieve my pain but only to the extent the medication wouldnot seriously threaten to shorten my life."  OR "I would like medication to relieve my pain but only to the extent it is known, to areasonable medical certainty, that it will not shorten my life." Think carefully about any special conditions you decide to write in your "Will to Live." You may want to show them to your intended agent and a couple of other people to see if theyfind them clear and if they mean the same thing to them as they mean to you.  Remember thathow carefully you write may literally be a matter of life or death--your own. AFTER WRITING DOWN YOUR SPECIAL CONDITIONS, IF ANY, YOU SHOULD MARK OUTTHE REST OF THE BLANK LINES LEFT ON THE FORM FOR THEM (JUST AS YOU DO AFTERWRITING OUT THE AMOUNT ON A CHECK) TO PREVENT ANY DANGER THAT SOMEBODY OTHERTHAN YOU COULD WRITE IN SOMETHING ELSE.IT IS WISE TO REVIEW YOUR WILL TO LIVE PERIODICALLY TO ENSURE THAT IT STILLGIVES THE DIRECTIONS YOU WANT FOLLOWED.Robert Powell Center for Medical EthicsNational Right to Life www.nrlc.org  ~ (202) 378-8862

1How to use the Hawaii Will to Live FormSUGGESTIONS AND REQUIREMENTS1.This document allows you to designate (name) a health care agent - someone (who doesnot have to be a lawyer) who will make health care decisions for you whenever you areunable to make them for yourself.  It also allows you to give instructions concerningmedical treatment decisions that the health care agent must follow.  Any person who is atleast 18 years old or totally self-supporting may designate a health care agent through thisdocument.2.To execute a valid power of attorney, you must sign and date this document, which mustbe witnessed in one of two ways:A.)Signed by at least two individuals, each of whom witnessed either yoursigning of the document or your acknowledgment of the signature of thedocument (if someone signed the document for you in your presencebecause you were unable to do so); ORB.)Acknowledged before a notary public at any place within this state.3.A witness cannot be: (1) a health-care provider; (2) an employee of a health-care provideror facility; or (2) the designated agent.  At least one of the individuals used as a witnessfor a power of attorney for health care cannot be: (1) related to you by blood, marriage, oradoption; or (2) entitled to any portion of your estate upon your death under any will ordocument existing at the time of execution of this document or by operation of law thenexisting.4.It is helpful to designate successor health care agent(s) to take over if your first choice isunable to serve.  There is space on this form for you to designate two successor agent(s).5.You should tell your doctor about this document.  You should also ask your doctor tokeep a copy of this document as a part of your medical health record.6.Your health care agent’s authority takes effect only when you no longer have the capacityto make and communicate your own health care decisions.7.This document will remain in effect until you revoke (cancel) it.  You may revoke thedesignation of an agent only by a signed writing or by personally informing the

Under State law, though, a decree of annulment, divorce, dissolution of marriage, or legal separation 2revokes a previous designation of a spouse as your agent, unless the decree specifies otherwise.2supervising health-care provider.  You may revoke all or part of this health care directive 2(other than the designation of your agent) at any time in any manner that communicatesan intent to revoke.8.This type of document has been authorized by the Hawaii Health-Care Decisions Act,Hawaii Rev. Stat. §§327E-1 to 327E-16.9.You should periodically review your document to be sure it complies with your wishes. Before making changes, be aware that it is possible that the statutes controlling thisdocument have changed since this form was prepared.  Contact the Will to Live Projectby visiting www.nrlc.org  (Click on “Will to Live”) or an attorney to determine if thisform can still be used.10.If you have any questions about this document, or want assistance in filling it out, pleaseconsult an attorney.For additional copies of the Will to Live, please visit www.nrlc.org.Form prepared 2001Updated 2008

1 of 5Hawaii Power of Attorney for Health CareWill to Live FormDESIGNATION OF AGENTI, (your name)__________________________________________________________________(your address)_______________________________________________________________________________________________________________________________________________(your phone number)____________________________________________________________designate the following individual as my agent to make health-care decisions for me:(Name of agent)________________________________________________________________(address of agent)_______________________________________________________________(phone number(s) of agent)_______________________________________________________OPTIONAL: If I revoke my agent’s authority, or if my agent is not willing, able, or reasonablyavailable to make health-care decisions for me, I designate as my first alternate agent:First Successor Agent(successor agent’s name)_________________________________________________________(successor agent’s address)_____________________________________________________________________________________________________________________________________(successor agent’s phone number)__________________________________________________OPTIONAL: If I revoke the authority of my agent and first alternate agent, or if neither iswilling, able, or reasonably available to make health-care decisions for me, I designate as mysecond alternate agent:Second Successor Agent(second successor agent’s name)___________________________________________________(second successor agent’s address)________________________________________________________________________________________________________________________________(second successor agent’s phone number)____________________________________________WHEN AGENT’S AUTHORITY BECOMES EFFECTIVEMy agent’s authority becomes effective when my primary physician determines that I am unableto make my own health-care decisions unless I mark the following box.  If I mark this box, myagent’s authority to make health-care decisions for me takes effect immediately.

2 of 5My agent’s authority to make health-care decisions takes effect immediately.NOMINATION OF GUARDIANIn the event a court appoints a guardian on my behalf, I nominate the agent designated in thisform.  If that agent is not willing, able, or reasonably available to act as guardian, I nominate thealternate agents whom I have named, in the order designated.INSTRUCTIONS FOR HEALTH CARE:GENERAL PRESUMPTION FOR LIFEI direct my health care provider(s) and my health care agent(s) to make health care decisionsconsistent with my general desire for the use of medical treatment that would preserve my life, aswell as for the use of medical treatment that can cure, improve, reduce or prevent deteriorationin, any physical or mental condition.Food and water are not medical treatment, but basic necessities.  I direct my health careprovider(s) and my health care agent to provide me with food and fluids, orally, intravenously, bytube, or by other means to the full extent necessary both to preserve my life and to assure me theoptimal health possible.I direct that medication to alleviate my pain be provided, as long as the medication is not used inorder to cause my death.I direct that the following be provided: Cthe administration of medication; Ccardiopulmonary resuscitation (CPR); and Cthe performance of all other medical procedures, techniques, and technologies,including surgery,–all to the full extent necessary to correct, reverse, or alleviate life-threatening or healthimpairing conditions or complications arising from those conditions.I also direct that I be provided basic nursing care and procedures to provide comfort care.I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ ofan unborn or newborn child, who has been subject to an induced abortion.  This rejection doesnot apply to the use of tissues or organs obtained in the course of the removal of an ectopicpregnancy.I also reject any treatments that use an organ or tissue of another person obtained in a manner thatcauses, contributes to, or hastens that person’s death.

3 of 5I request and direct that medical treatment and care be provided to me to preserve my life withoutdiscrimination based on my age or physical or mental disability or the “quality” of my life.  Ireject any action or omission that is intended to cause or hasten my death.I direct my health care provider(s) and my health care agent to follow the policy above, even if Iam judged to be incompetent.During the time I am incompetent, my health care agent(s) named above is authorized to makemedical decisions on my behalf, consistent with the above policy, after consultation with myhealth care provider(s), utilizing the most current diagnoses and/or prognosis of my medicalcondition, in the following situations with the written special instructions.WHEN MY DEATH IS IMMINENTA.  If I have an incurable terminal illness or injury, and I will die imminently – meaning that areasonably prudent physician, knowledgeable about the case and the treatment possibilities withrespect to the medical conditions involved, would judge that I will live only a week or less evenif lifesaving treatment or care is provided to me – the following may be withheld or withdrawn:(Be as specific as possible; SEE SUGGESTIONS.):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Cross off any remaining blank lines.)WHEN I AM TERMINALLY ILLB.  Final Stage of Terminal Condition.  If I have an incurable terminal illness or injury and eventhough death is not imminent I am in the final stage of that terminal condition – meaning that areasonably prudent physician, knowledgeable about the case and the treatment possibilities withrespect to the medical conditions involved, would judge that I will live only three months or less,even if lifesaving treatment or care is provided to me – the following may be withheld orwithdrawn:(Be as specific as possible; SEE SUGGESTIONS.):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Cross off any remaining blank lines.)C.  OTHER SPECIAL CONDITIONS:

4 of 5(Be as specific as possible; SEE SUGGESTIONS.):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________(Cross off any remaining blank lines.)IF I AM PREGNANTD.  Special Instructions for Pregnancy.  If I am pregnant, I direct my health care provider(s) andmy health care agent(s) to use all lifesaving procedures for myself with none of the above specialconditions applying if there is a chance that prolonging my life might allow my child to be bornalive.  I also direct that lifesaving procedures be used even if I am legally determined to be braindead if there is a chance that doing so might allow my child to be born alive.  Except as I specifyby writing my signature in the box below, no one is authorized to consent to any procedure forme that would result in the death of my unborn child. If I am pregnant, and I am not in the final stage of a terminal condition as defined above,medical procedures required to prevent my death are authorized even if they may result in thedeath of my unborn child provided every possible effort is made to preserve both my life and thelife of  my unborn child.____________________________________Signature of DeclarantEFFECT OF COPYA copy of this form has the same effect as the original.Signed this ____________________day of ___________________________, 20_______.(Signature)____________________________________________________________________(Print Name)___________________________________________________________________WITNESSESThis 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 presentwhen you sign or acknowledge your signature; or (b) acknowledged before a notary public in thestate.FIRST ALTERNATIVE I declare under penalty of false swearing pursuant to §710-102, Hawaii Revised Statutes, that theprincipal is personally known to me, that the principal signed or acknowledged this power ofattorney in my presence, that the principal appears to be of sound mind and under no duress,

5 of 5fraud, or undue influence, that I am not the person appointed as agent by this document, and thatI am not a health-care provider, nor an employee of a health-care provider or facility.  I am notrelated to the principal by blood, marriage, or adoption, and to the best of my knowledge, I amnot entitled to any part of the estate of the principal upon the death of the principal under a willnow existing or by operation of law.First Witness Signature:__________________________________________________________Date:__________________________________Address:____________________________Print Name:________________________________________________________________I declare under penalty of false swearing pursuant to §710-102, Hawaii Revised Statutes, that theprincipal is personally known to me, that the principal signed or acknowledged this power ofattorney 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 thatI am not a health-care provider, nor an employee of a health-care provider or facility. Second Witness Signature:________________________________________________________Date:__________________________________Address:____________________________Print Name:________________________________________________________________SECOND ALTERNATIVENOTARY PUBLICState of HawaiiCounty of________________________On this ________ day of ____________________, 20_____, before me (name of notary public)______________________________________, personally known to be (or proved to me on thebasis of satisfactory evidence) to be the person whose name is subscribed to this instrument, andacknowledged that he or she executed it.Notary Seal__________________________________________Signature of Notary PublicMy commission expires:______________________Form prepared 2001Updated 2008