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Hawaii Advance Health Care Directive Form 1

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Hawaii Advance Health Care Directive Form 1
Hawaii Advance Health Care Directive Form 1
HAWAII
ADVANCE HEALTH-CARE DIRECTIVE
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 health-care 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:
(a) Consent or refuse consent to any care, treatment, service, or procedure to maintain, diagnose, or otherwise
affect a physical or mental condition;
(b)Select or discharge health-care providers and institutions;
(c) Approve or disapprove diagnostic tests, surgical procedures, programs of medication, and orders not to resus-
citate; and
(d)Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of
health care.
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 alter-
native 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 under-
stands 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
HEALTHCARE DECISIONS
(1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health-care decisions
for me:
Name: ____________________________________________________________________________________
Address: __________________________________________________________________________________
____________________________________ Zip Code: __________________________________
Home Phone: _______________________________ Work Phone: ________________________________
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:
ABAAAEAZ
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