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Durable Power Of Attorney Advance Health Care Directive (Hawaii) POA-HI 100 - Legal Forms
| Durable Power Of Attorney Advance Health Care Directive (Hawaii) Form. This is a Legal Forms form and can be used in Health Care-Living Wills Power Of Attorney . |
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Hawaii Advance Health-Care Directive (Section §327E-16) Explanation You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding the designation of your health-care provider. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may name an alternate agent to act for you if your first choice is not willing, able, or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator, or employee of a health-care institution where you are receiving care. Unless the form you sign limits the authority of your agent, your agent may make all health-care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all healthcare decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to: (1) Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect a physical or mental condition; Select or discharge health-care providers and institutions; Approve or disapprove diagnostic tests, surgical procedures, programs of medication, and orders not to resuscitate; and Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care. (2) (3) (4) Part 2 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief medication. Space is provided for you to add to the choices you have made or for you to write out any additional wishes. Part 4 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end and have the form witnessed by one of the two alternative methods listed below. Give a copy of the signed and completed form to your physician, to any other health-care providers you may have, to any health-care institution at which you are receiving care, and to any health-care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility. You have the right to revoke this advance health-care directive or replace this form at any time. PART - 1 DURABLE POWER OF ATTORNEY FOR HEALTH CARE DECISIONS: I designate as my agent to make health-care decisions for me. Address Phone . If I revoke my agent's authority or if my agent is not willing, able or reasonably available to act, I designate as my first alternate agent . Except as limited herein, my agent shall make health-care decisions for me in accordance with this power of attorney for health care, any instructions I give in this form, and any other wishes of mine to the extent known to my agent, including decisions to provide, withhold, or withdraw artificial nutrition and hydration, and all other forms of health care to keep me alive. To the extent my wishes are unknown or unspecified, my agent shall make health-care decisions for me in accordance with what my agent determines to be in my best interest, taking into account my personal values to the extent known to my agent. If a guardian of my person needs to be appointed for me by a court, I nominate my acting agent designated in this form. I direct that my health-care/care providers provide, withhold, or withdraw treatment in accordance with this directive. WHEN THIS DIRECTIVE BECOMES EFFECTIVE My agent's authority becomes effective when my primary physician determines that I am unable to make my own health-care decisions; or, My agent's authority is effective immediately. PART 2 - INSTRUCTIONS FOR HEALTH CARE I provide the following specific health care directions: Choice Not To Prolong Life. I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the likely risks and burdens of treatment would outweigh the expected benefits. Choice To Prolong Life. I want my life to be prolonged as long as possible within the limits of generally accepted health-care standards. Artificial Nutrition and Hydration must be provided, withheld or withdrawn in accordance with my choice whether or not to prolong life which I have made, above. Artificial Nutrition and Hydration must be provided regardless of my condition and regardless of my choice whether or not to prolong life which I have made, above. Treatment and Medications to alleviate pain or discomfort should be provided even if they hasten my death. PART 3 - DONATION OF ORGANS AT DEATH (OPTIONAL) Upon my death: (mark applicable boxes and strike any parts that do not apply) I give any needed organs, tissues, or parts. I give the following organs, tissues, or parts only . My gift is for the following purposes: Transplant, Therapy, Research, Education SPECIAL PROVISIONS PART 4 - PRIMARY PHYSICIAN (OPTIONAL) I designate the following as my primary physician: Name: Address: Phone: COPIES / REVOCATION: A copy of this form has the same effect as the original. I reserve the right to revoke this advance health-care directive or replace this form at any time. SIGNATURE: Date: ALTERNATIVE NO. 1 WITNESSES: This power of attorney will not be valid for making healthcare decisions unless it is EITHER (a) signed by two qualified adult witnesses (not related, not health care providers) 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 sta
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