ADVANCE
HEALTH CARE DIRECTIVE
MY NAME IS
MY ADDRESS IS:
(Address) (City)
(State) (Zip
code)
PART 1
DURABLE POWER OF ATTORNEY FOR HEALTH
CARE DECISIONS
(1)
DESIGNATION OF AGENT: I designate the following individual as my agent
to make health care decisions for me:
(Name of individual you choose as agent)
(Address) City) (State)
(Zip code)
(Home phone)
(Work phone) (E-Mail or other means of contact)
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 agent:
(Name of individual you choose as first
alternate agent)
(Address)
(City) (State) Zip
code)
(Home phone)
(Work phone) (E-Mail
or other means of contact)
OPTIONAL: If I revoke the authority of 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:
(Name of individual you choose as second
alternate agent)
(Address)
(City) (State)
Zip
code)
(Home phone) (Work phone)
(E-Mail or other means to contact)
(2) AGENTÕS AUTHORITY: (Strike through
any of the following provisions you do not want. You can add provisions on the
form or attach additional pages.)
My agent is authorized to make all of the
following health care decisions for me:
á
To consent
or refuse consent to any care, treatment, service, or procedure to maintain,
diagnose, or otherwise affect a physical or mental condition, including
admission to or discharge from a health care facility or program, approval or
disapproval of diagnostic tests, medical or surgical procedures, programs of
medication, the use of alternative or complementary therapies as well as
decisions to participate in education, research and experimental programs.
á
To make decisions
regarding orders not to resuscitate, including out-of-hospital ÒComfort Care
OnlyÓ documents, as well as decisions to provide, withhold, or withdraw
nutrition and hydration, and all other forms of health care to keep me alive.
á
To request,
receive, examine, copy, and consent to the disclosure of medical or any other
health care information, including medical files and records. This includes my
delegated authority for my agent to act as my personal representative for
release of all individually identifiable health information concerning me by
both covered and non-covered entities under the provisions of the Health
Insurance Portability and Accountability Act (HIPAA) and/or other Federal and
State laws pertaining to healthcare and healthcare information.
á
To
communicate with, select and discharge health care providers, organizations,
institutions and programs, including hospice programs and to make and change
health care choices and options relating to plans, services, and benefits.
á
To apply
for public or private health care programs
and benefits, to include Medicare, Medicaid, Med-Quest or other federal, state,
local or private programs without my agent incurring any personal financial
liability.
á
To make all
other health care decisions for me, except as I state here:
(Consult with a mental health
professional and/or attorney for appropriate language if you wish to give your
agent additional information or instructions about decisions regarding mental
illness. You may make a separate mental illness advance directive or include
such provisions in this advance directive. Use additional sheets if needed.)
(3) WHEN AGENT'S AUTHORITY BECOMES
EFFECTIVE: My agentÕs authority becomes effective when my primary physician
determines that I am unable to make my own health care decisions unless I mark
the following box.
____ c
If I mark this box, my agent's authority to make health care decisions
for me takes effect immediately.
However, I always retain the right to make my own decisions about my
health care and to revoke this authority as long as I am mentally capacitated.
(4) AGENTÕS OBLIGATION: 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 my 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 consider my personal values to the extent known to my
agent. My agent shall not be
obligated to assume any personal financial responsibility when making decisions
in accordance with this document.
(5) NOMINATION OF GUARDIAN: If a guardian of my person needs
to be appointed for me by a court, I nominate my agent. If another person is
appointed as guardian and my agent is willing and able to act, I would prefer
my agent to have precedence in making health care decisions for me.
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you are satisfied with allowing 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 form, you may strike through 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 accordance with the choice I have marked below: (Check only one of the two following
boxes. You may cross out any
unwanted provisions.)
____ c
(a) Choice Not To
Prolong Life
I do not want my life to be prolonged if
á
I am close
to death and life support would only postpone the moment of my death or I have
an incurable and irreversible condition that will result in my death within a
relatively short time; or
á
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 again; or
á
I have brain damage or a brain disease that makes me permanently unable to interact and make
and communicate health care decisions about myself and the likely risks and
burdens of treatment would outweigh the expected benefits.
OR
____ c
(b) Choice To Prolong
Life
á
I want my
life to be prolonged as long as possible within the limits of generally
accepted health care standards.
(7) ARTIFICIAL 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.
____ c
If 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
the following box,
____ c I 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 write your own, or if you wish to add to the instructions you
have given above, you may do so here. Examples of additional instructions
include preferences to receive Hospice Care and/or to die at home.) I direct that:
PART 3
DONATION OF ORGANS/BODY AT DEATH (OPTIONAL)
(10) Upon my death: (Mark applicable
box(es).
____ c (a) I give any needed organs, tissues,
or parts, OR
____ c (b) I give the following organs,
tissues, or parts only
_________________________________________________________________
____ c (c) My gift is for the following
purposes
(Strike through any of the following you do not want)
á
Transplant
á
Therapy
á
Research
á
Education
____ c
(d) I give my body to the
John A. Burns School of Medicine for its research and education purposes. (Obtain
information/forms from the medical school Department of Anatomy)
PART 4
PRIMARY PHYSICIAN/HEALTH -CARE
FACILITY (OPTIONAL)
(11) I designate the following physician
as my primary physician:
(Name of physician)
(Address) (City)
(State) (Zip code) (Phone)
OPTIONAL: If the physician I have designated above is not willing,
able, or reasonably available to act as my primary physician, I designate the
following physician as my primary physician:
(Name of physician)
(Address)
(City) (State)
(Zip code) (Phone)
(12) I have the following preference of hospitals and/or
nursing homes if I require such care:
(You may name a facility, or you may
indicate a preference for hospice care administered at home or in a hospice
facility, a preference not to be institutionalized, a preference to remain at
home, etc.)
PART 5
RELIGIOUS OR SPIRITUAL
INFORMATION (OPTIONAL)
(13) I identify with the following
church, temple, or other spiritual group:
(14) I would like to receive my spiritual
care from:
(Name of individual or group)
(Address) (City)
(State) (Zip
code) (Phone)
(15) EFFECT OF COPY: A copy of this form has the same effect
as the original.
SIGNATURE: Sign and date the form here:
_________________________________ ______________________
(Sign Your Name) (Date)
_________________________________
(Print Your Name)
WITNESSES: The power of attorney portion
of this document 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 present when you sign or acknowledge your signature; or (b)
acknowledged before a notary public in the state.
ALTERNATIVE NO.
1
First 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
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 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 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 principal under a will now existing or by operation of law.
____________________________ ______________________________
(Signature of Witness) (Date)
____________________________ ______________________________
(Printed Name of Witness) (Address
of Witness)
Second 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
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 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 facility.
____________________________ ______________________________
(Signature of Witness) (Date)
____________________________ ______________________________
(Printed Name of Witness) (Address
of Witness)
ALTERNATIVE NO.
2
State of HawaiÕi
City and County of Honolulu
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 satisfactory evidence)
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)
My Commission
Expires:__________