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Hawaii Advance Health Care Directive Form

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A Hawaii advance health care directive allows a person to select a medical care agent to handle their health treatment wishes. The form gives also gives instructions to medical staff on how to be treated in the event of being incapacitated permanently. For these reasons, advance directives are common for the elderly or any individual seeking a health care plan.

Table of Contents

Laws

Statute – Chapter 327E (Uniform Health Care Decisions)

Signing Requirements (§ 327E-3(b)) – Two (2) witnesses or a notary public.

State Definition (§ 327E-2) – “Advance health-care directive” means an individual instruction or a power of attorney for health care.

Versions (4)


 

Catholic Diocese of Hawaii

Download: Adobe PDF

 

 

 


Hawaii.edu

Download: Adobe PDF

 

 

 


Hawaii.gov

Download: Adobe PDF

 

 

 


Kokua Mau

Download: Adobe PDF

 

 

 


 

How to Write

Download: Adobe PDF

Step 1 – Secure The Hawaii Advance Health Care Directive Form

Use the “PDF” button furnished on this page to save the Hawaii Advance Health Care Directive Form to your machine. The “Microsoft Excel (.xlsx)” link in this area will allow the same file to be downloaded.

Step 2 – Establish The Date Of This Issue

This directive is expected to be a representation of its Principal’s wishes as of a specific “Date.” Therefore, the first report that must be produced is the “Date” when this document is developed. The upper-right hand corner of this paperwork will present the blank line labeled “Date” so this production will be easily noticed upon review. 

Step 3 – Identify The Hawaii Resident Acting As Principal

The full name of the Principal issuing this Hawaii directive is the next fact that must be discussed. The next blank line will run across the top of the page and be divided (by label) into three areas of entry. The “Last” name of the Principal will be the first requested item while the “First” and “Middle” name will be concluding requests for this line.  Once the name of the Hawaii Principal has been documented, continue to the next line down. This too will be divided into three areas of entry. The building number, street, and apartment number where the Principal resided in Hawaii should be recorded above the term “Street Address” leaving the “City,” “State,” and “Zip Code” of the Principal’s home address to be delivered to the remainder of this line.  

 

Step 4 – Dispense The Principal’s Residential Address In Hawaii

Review the introduction to “Part 1: Individual Instructions For Health Care.” This directive will make use of statement items that define the Principal’s wishes should any of the scenarios defined by this introduction occur, thus allowing for a clear presentation of the Principal’s preferences when rendered dependent on life support simply to prolong death, is in an “Irreversible Coma,” becomes unable to make health care decisions, or has been incapacitated but conscious and unable to deliver treatment decisions in a way that may be understood by attending Medical Personnel. 

 

Step 5 – Report The Principal’s Position On Prolonging Life

If the Principal is subjected to any of the conditions defined in the introduction, then he or she will eventually be presented with the “Choice To Prolong Or Not To Prolong Life.” the Principal can take part in such a discussion in item A by reviewing the choices it presents then initialing the statement that he or she wishes applied. If the Principal wishes his or her life prolonged for “As Long As Possible” then he or she must initial the line attached to the “Yes, I Do Want To Have My Life Prolonged…”  Conversely, if the Principal wants to declare that his or her life should not be maintained or prolonged when death is imminent or when permanently incapacitated then he or she must initial the empty line corresponding to the second statement of item A (“No, I Do Not Want My Life Prolonged”). 

 

Step 6 – Document The Principals Decision On Remaining Hydrated And Fed

The next topic will be addressed by the second item, “B. Artificial Nutrition And Hydration (Food And Fluids) By Tube Into Stomach Or Vein,” and will also require the Principal’s direct attention. The first statement choice should be initialed if the Principal wishes Medical Staff to know that artificial nutrition and hydration procedures should be engaged when deemed necessary even when there’s very little to no hope of recovery from being unconscious, incapacitated, or at an end-of-life event.  If the Principal intends to refuse being administered artificial nutrition and hydration through the stomach or intravenously (through an I.V.) when faced with an end-of-life event or permanently (or nearly) comatose then the second statement should be initialed on the line attached to “No, I Do Not Want…” 

 

Step 7 – Discuss The Principal’s Willingness To Endure Pain

A third item (C) will discuss the Principal’s option to gain “Relief From Pain” through the efforts of Medical Personnel. Therefore, if the Principal intends to continue or allow the attending Medical Staff to provide “Relief From Pain” then he or she must initial the “Yes…” statement.  The “No” statement in this option should be initialed if the Principal wishes to make sure that Medical Staff understands that he or she will not consent to “Relief From Pain” when faced with one of the scenarios in the introduction.

 

Step 8 – Indicate If The Principal Requires Religious Or Spiritual Care

Some Hawaii Principals may wish to engage in religious or spiritual practices, observances, or counseling when faced with imminent death or permanent incapacitation. If the Principal behind the Hawaii Directive has these concerns, then this paperwork may be used to provide the contact information needed by the Medical Staff or Health Care Agent so this concern may be addressed even if the Principal cannot directly participate. In “D. Ethical, Religious, Or Spiritual Instructions (Optional)” the full “Name” and “Phone” number of the “Church, Temple, Spiritual Group,” or Specific Religious or Spiritual Counselor or Leader should be reported to the labeled areas of the blank line in item D.  The next line in item D is set to receive the “Street Address,” the “City” and “State,” then the “Zip Code” where the Religious or Spiritual Authority in the Principal’s life may be reached.  

 

Step 9 – Furnish The Principal’s Decision On Hospice Care

Many Principals will wish for the comfort and support of Hospice Care when they are unable to care for themselves during an end-of-life event. Item “E. Do You Want Hospice Care, If Appropriate” presents a “Yes” checkbox and a “No” checkbox. To answer this question by indicating that the Principal wishes to receive Hospice Care when it is time he or she must mark or check the box labeled “Yes” in item E.  If the Principal does not wish to receive Hospice Care when death is imminent and he or she can no longer survive independently then, the “No” box must be marked or checked. 

 

Step 10 – Identify The Hawaii Resident’s Regular Physician

The Principal’s “Primary Care Physician” can be listed by “Name” and “Phone” number in item F. Many would suggest this information be provided in case one’s medical history is pertinent or vital to receiving the proper treatment.

 

Step 11 – Indicate Where Attached Additional Instructions Are Filed

Item “G. Other Wishes” enables additional directives to be included from the Principal. These preferences can be documented in a separate document then attached. Additionally, such attachments must be provided with this document to the relevant Parties. To this end, if an attachment with additional Principal directives or preferences is provided, indicate which (if any) Parties have received such paperwork by marking the checkbox with the appropriate label in this section (“Doctor Copy,” “Family Copy,” and “Agent Copy.” Any checkbox marked or checked will indicate where a copy of the Principal’s directives may be found.   

 

Step 12 – Produce The Name Of The Hawaii Agent Who Will Wield Principal Powers

This document continues to “Part 2: Health-Care Power Of Attorney Agent’s Authority And Obligation” where the Principal can appoint a specific Party to act as his or her voice with Medical Staff when incapacitated or unconscious with little to no hope of improvement. The first blank line in this part of the document, labeled “Name Of Agent…,” requires that the full name of the Person who the Principal has elected to represent him or her be submitted and his or her relation to the Principal documented above the “Relationship” label. 

 

Step 13 – Submit A Production Of The Agent’s Address

The Agent’s “Address,” “City,” “State,” and “Zip” code must be delivered to the second blank line of this paperwork. Be advised this should be the home address of the Principal’s Agent.

 

Step 14 – Present The Hawaii Agent’s Direct Means Of Contact

Once the address of the Agent has been delivered, locate the line holding the labels “Phone,” “Work Phone,” and “E-Mail” then fill in his or her current contact material. Present the telephone numbers and email address where the Agent can be contacted quickly (if needed).   

 

Step 15 – Supply The Alternate Hawaii Agent’s Identity

The Hawaii Principal can also use this issuance to reserve an Alternate Health Care Agent. This is an individual who will not hold any authority to represent the Principal with unless the Primary Health Care Agent has stepped down, had his or her powers revoked, or is otherwise unable to represent the Principal and named on the first blank line in “Part 2: Health-Care Power Of Attorney Of Agent’s Authority And Obligation.” Once this information is documented, use the space over “Relationship” to define what role the Alternate Agent plays in the Principal’s life. 

Step 16 – Input The Alternate Hawaii Agent’s Address

The next line down should be supplied with the Hawaii Alternate Agent’s home address. Compose this report of the “Street Address, “City,” “State,” and “Zip Code” by following the labeled areas displayed.

 

Step 17 – Enter Additional Means of Contact For The Alternate Agent

Lastly, the Hawaii Alternate Agent’s telephone numbers should be produced over the label “Home Phone” and “Work Phone.” Both these items must enable any Reviewer of this paperwork to contact the Alternate Agent immediately. The second part of this line will seek the “E-Mail” address where the Hawaii Alternate Agent can be contacted.  

 

Step 18 – Indicate The Extent Of the Agent’s Power Regarding The Principal’s Directive

Since the first part of this paperwork has been completed directly by the Principal, some basic prioritization set by the Principal will need to be established for the benefit of Medical Personnel reviewing it. Therefore, if the Principal’s Health Care Agent has the authority to fully represent the Principal’s medical decisions then the first statement should be initialed by the Principal. If the Principal will only allow the Health Care Agent a limited amount of representational powers, then he or she should initial the second presented statement. This choice also requires a production of every type of medical decision restricted from the Agent’s powers on the blank line after the word “…Except.” 

 

Step 19 – Set The Date Of Effect In Writing

The next issue that should be dealt with pertaining to the extent of the Health Care Agent’s powers concerns when they become effective. If the Agent’s authority to represent the Principal should not become effective unless the Principal’s Physician declares him or her incapacitated or uncommunicative then the first statement beginning with the phrase “My Agent’s Authority…” should be initialed by the Principal.  If the Principal wishes the Health Care Agent’s ability and power to make health care decisions on his or her behalf to become active or effective immediately upon issuing this paperwork, then the second statement of these choices.  

 

Step 20 – Execution Of This Document Requires the Hawaii Principal’s Attention

This paperwork shall deliver the authority to make medical decisions on behalf of the issuing Principal therefore, only the Principal may place it in effect. This requires written proof of his or her desire to elect a Health Care Agent for this type of representation. To this effect, the Principal must locate the “Your Name” line then print his or her name, sign his or her name, then document the “Date” he or she supplied these items on the blank line bearing the labels “Print Your Name,” “Your Signature,” and “Date.”

 

Step 21 – Confirm The Hawaii Principal’s Signature By Witness

One of two areas that follow the Principal’s execution area must be completed to authenticate this paperwork. If the Principal has decided to sign this directive before two Witnesses in Hawaii, then he or she must give the document to the Witnesses once it is signed. Each Witness must sign read the statement following the term “Important: Witnesses. If Witness 1 meets this criterion he or she must print, sign, and date the blank line next to the words “Option 1: Witnesses” using the areas marked “Witness #1 Print Name,” “Witness Signature,” and “Date” to testify that he or she is a qualified Witness who has observed the Principal signing.  After verifying his or her qualifications then attesting to the validity of the Principal’s signature, Witness #1 must provide a record of his or her “Address,” “City, “State,” and “Zip Code” of residence to the next line.  The second Witness must print his or her name above the words “Witness #2 Print Name” then sign his or her name to the space that follows (above the words “Witness Signature” and furnish the “Date” he or she provided this testimony.  Witness #2 must also provide his or her complete residential address in Hawaii to the next line utilizing the areas labeled “Address,” “City, “State,” and “Zip Code” to do so.  

 

Step 22 – Authenticate This Signing With A Notary Public

“Option 2: Notary Public” provides an alternate method for validating the Principal’s signing. If a Notary Public is being used, the Principal must follow his or her singing instructions, then review the notarized document. The Notary Public’s section is only complete if it lists the state, date, and parties involved with this signing then document the credentials of the notary.   

 

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