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) AGENTS 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:

      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.

      To make decisions regarding orders not to resuscitate, including out-of-hospital Comfort Care Only documents, as well as decisions to provide, withhold, or withdraw nutrition and hydration, and all other forms of health care to keep me alive.

      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.

      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.

      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.

      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 agents 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) AGENTS 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

      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

      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

      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

      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)

      Transplant

      Therapy

      Research

      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 Hawaii

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:__________