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Hawaii Advance Health Care Directive Form 2

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Hawaii Advance Health Care Directive Form 2
Hawaii Advance Health Care Directive Form 2
Your Name: Last First Middle initial
Street Address City State Zip
Part 1: INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE
The following statements only apply
• if I am close to death and life support would only postpone the moment of my death OR
• if 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 OR
• if I have brain damage or a brain disease that makes me permanently unable to make and communicate health-care deci-
sions about myself.
(INITIAL ONLY ONE (1) CHOICE IN EACH SECTION and CROSS OUT ALL THAT DO NOT APPLY.)
A. CHOICE TO PROLONG OR NOT TO PROLONG LIFE
____ YES, I do want to have my life prolonged as long as possible within the limits of generally accepted health-care
standards that apply to my condition.
OR
____ NO, I do not want my life prolonged.
B. A
RTIFICIAL NUTRITION AND HYDRATION (FOOD AND FLUIDS) BY TUBE INTO STOMACH OR VEIN
____ YES, I do want artificial nutrition and hydration.
OR
____ NO, I do not want artificial nutrition and hydration.
C. R
ELIEF FROM PAIN
____ YES, I do want treatment to relieve my pain or discomfort.
OR
____ NO, I do not want treatment to relieve my pain or discomfort.
D. E
THICAL, RELIGIOUS, OR SPIRITUAL INSTRUCTIONS (OPTIONAL)
Is there a church, temple, spiritual group or a special person from whom you wish to receive spiritual care
Name: Phone
Street Address City State Zip
E. DO YOU WANT HOSPICE CARE, IF APPROPRIATE ____ YES ____ NO
(Hospice provides physical, psychosocial, emotional, and spiritual support and counseling for the patient and his/her family.
Hospice is available in home, hospital, hospice-unit, and nursing home settings.)
F. P
RIMARY CARE PHYSICIAN
Name: Phone
G. OTHER WISHES:
If you do not agree with any of the choices above or wish to add other instructions, including body and organ donation,
you may add pages. If you are or could become pregnant, consult your doctor, and consider adding special instructions
suspending or adding provisions. Remember to sign, date, witness or notarize additional pages. File a copy with:
Doctor copy Family Copy Agent Copy www.myhealthdirective.com
ADVANCE HEALTH CARE DIRECTIVE FORM
Date:
Hawaii Advance Health Care Directive Form 2
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