327G-14. Optional form
The following sample form may be used to create an advance mental health care directive. This sample form may be duplicated, or modified to suit the needs of the person. Any written document that contains the substance of the following information may be used in an advance mental health care directive:
"ADVANCE MENTAL HEALTH CARE DIRECTIVE
Explanation
You
have the right to give instructions about your own mental health care. You
also have the right to name someone else to make mental health treatment
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
providers. 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 list of options you may designate as part of your mental
health care and treatment. For ease of designating specific instructions, mark
those options in Part 1.
Part 2
of this form is a power of attorney for mental health care. This lets you name
another individual as your agent to make mental health treatment 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 of making your own decisions. You may name alternate agents 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.
You may
allow your agent to make all mental health treatment decisions for you.
However, if you wish to limit the authority of your agent, you may specify
those limitations on the form. If you do not 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 mental condition;
(2) Select or
discharge health care providers and institutions;
(3) Approve
or disapprove diagnostic tests, surgical procedures, and programs of
medication; and
(4) Approve
or disapprove of electroconvulsive treatment.
Part 3
of this form lets you give specific instructions about any aspect of your
mental health care and treatment. Choices are provided for you to express your
wishes regarding the provision, withholding, or withdrawal of medication and
treatment. 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 must be completed in order to activate the advance mental health
care directive. After completing this form, sign and date the form at the end
and have the form witnessed by one or both of the two 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 mental health care agents you have named. You
should talk to the persons you have named as agents to make sure that they
understand your wishes and are willing to take the responsibility.
You
have the right to revoke this advance mental health care directive or replace
this form at any time, unless otherwise specified in writing in the advance
mental health care directive.
If you
are in imminent danger of causing bodily harm to yourself or others, or have
been involuntarily committed to a health care institution for mental health
treatment, the advance mental health care directive will not apply.
PART 1
CHECKLIST OF MENTAL HEALTH CARE OPTIONS
NOTE TO
PROVIDER: The following is a checklist of selections I have made regarding my
mental health care and treatment. I include this statement to express my
strong desire for you to acknowledge and abide by my rights, under state and
federal laws, to influence decisions about the care I will receive.
(Declarant:
Put a check mark in the left-hand column for each section you have completed.)
___ Designation
of my mental health care agent(s).
___ Authority
granted to my agent(s).
___ My
preference for a court appointed guardian.
___ My
preference of treating facility and alternatives to hospitalization.
___ My
preferences about the physicians or other mental health care providers who will
treat me if I am hospitalized.
___ My
preferences regarding medications.
___ My
preferences regarding electroconvulsive therapy (ECT or shock treatment).
___ My
preferences regarding emergency interventions (seclusion, restraint,
medications).
___ Consent
for experimental drugs or treatments.
___ Who
should be notified immediately of my admission to a facility.
___ Who
should be prohibited from visiting me.
___ My
preferences for care and temporary custody of my children or pets.
___ Other
instructions about mental health care and treatment.
PART 2
DURABLE POWER OF ATTORNEY FOR MENTAL HEALTH
TREATMENT DECISIONS
(1)
DESIGNATION OF AGENT: I designate the following individual as my agent to make
mental health care decisions for me:
___________________________________________________
(name
of individual you choose as agent)
___________________________________________________
(address)
(city) (state) (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 mental 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)
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 mental 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)
(2)
AGENT'S AUTHORITY: My agent is authorized to make all mental health care
treatment decisions for me, including decisions to provide, withhold, or
withdraw medication and treatment, and all other forms of mental health care,
except as I state here:
___________________________________________________
___________________________________________________
___________________________________________________
(Add
additional sheets if needed.)
(3)
WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes
effective when my supervising health care provider who is a physician and one
other physician or licensed psychologist determine that I am unable to make my
own mental health care decisions.
(4)
AGENT'S OBLIGATION: My agent shall make mental health care decisions for me in
accordance with this power of attorney for mental 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 mental 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.
(5)
NOMINATION OF GUARDIAN: If a guardian needs to be appointed for me by a court,
I nominate the agent designated in this form. If that agent is not willing,
able, or reasonably available to act as guardian, I nominate the alternate
agents whom I have named, in the order designated.
PART 3
INSTRUCTIONS FOR MENTAL HEALTH CARE AND
TREATMENT
If you
are satisfied to allow your agent to determine what is best for you, you need
not fill out this part of the form. If you do fill out this part of the form,
you may strike any wording you do not want.
(6) My
preference of treating facility and alternatives to hospitalization:
(7) My
preferences about the physicians or other mental health care providers who will
treat me if I am hospitalized:
(8) My
preferences regarding medications:
(9) My
preferences regarding electroconvulsive therapy (ECT or shock treatment):
(10) My
preferences regarding emergency interventions (seclusion, restraint,
medications):
(11)
Consent for experimental drugs or treatments:
(12)
Who should be notified immediately of my admission to a facility:
(13)
Who should be prohibited from visiting me:
(14) My
preferences for care and temporary custody of my children or pets:
(15) My
preferences about revocation of my advance mental health care directive during
a period of incapacity:
(16)
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.) I direct that:
___________________________________________________
___________________________________________________
___________________________________________________
(Add
additional sheets if needed.)
PART 4
WITNESSES AND SIGNATURES
(17)
EFFECT OF COPY: A copy of this form has the same effect as the original.
(18)
SIGNATURES: Sign and date the form here:
____________________________ ___________________________
(date) (sign
your name)
____________________________ ___________________________
(address) (print
your name)
____________________________
(city)
(state)
(19)
WITNESSES: This power of attorney will not be valid for making mental 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.
AFFIRMATION OF WITNESSES
Witness 1
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.
____________________________ ___________________________
(date) (sign
your name)
____________________________ ___________________________
(address) (print
your name)
____________________________
(city)
(state)
Witness 2
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.
____________________________ ___________________________
(date) (sign
your name)
____________________________ ___________________________
(address) (print
your name)
____________________________
(city)
(state)
DECLARATION OF NOTARY
State of Hawaii
County of
________________
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)"
[L 2004, c
224, pt of §2; am L 2005, c 22, §17]
