HRS §327E-1 Short title
327E-1. Short title
This chapter may be cited as the Uniform Health-Care Decisions Act (Modified).
L 1999, c
169, pt of §1
Uniform Health-Care Decisions Act (Modified)
HRS div. 1, tit. 19, ch. 0327E
in effectHRS §327E-2 Definitions
327E-2. Definitions
Whenever used in this chapter, unless the context otherwise requires:
"Advance health-care directive" means
an individual instruction or a power of attorney for health care.
"Agent" means an individual
designated in a power of attorney for health care to make a health-care
decision for the individual granting the power.
"Best interest" means that the
benefits to the individual resulting from a treatment outweigh the burdens to
the individual resulting from that treatment and shall include:
(1) The effect of the treatment on the physical,
emotional, and cognitive functions of the patient;
(2) The degree of physical pain or discomfort caused
to the individual by the treatment or the withholding or withdrawal of the
treatment;
(3) The degree to which the individual's medical
condition, the treatment, or the withholding or withdrawal of treatment,
results in a severe and continuing impairment;
(4) The effect of the treatment on the life
expectancy of the patient;
(5) The prognosis of the patient for recovery, with
and without the treatment;
(6) The risks, side effects, and benefits of the
treatment or the withholding of treatment; and
(7) The religious beliefs and basic values of the
individual receiving treatment, to the extent that these may assist the
surrogate decision-maker in determining benefits and burdens.
"Capacity" means an individual's
ability to understand the significant benefits, risks, and alternatives to
proposed health care and to make and communicate a health-care decision.
"Emancipated minor" means a person
under eighteen years of age who is totally self-supporting.
"Guardian" means a judicially
appointed guardian having authority to make a health-care decision for an
individual.
"Health care" means any care,
treatment, service, or procedure to maintain, diagnose, or otherwise affect an
individual's physical or mental condition, including:
(1) Selection and discharge of health-care providers
and institutions;
(2) Approval or disapproval of diagnostic tests,
surgical procedures, programs of medication, and orders not to resuscitate; and
(3) Direction to provide, withhold, or withdraw
artificial nutrition and hydration; provided that withholding or withdrawing
artificial nutrition or hydration is in accord with generally accepted health
care standards applicable to health-care providers or institutions.
"Health-care decision" means a
decision made by an individual or the individual's agent, guardian, or
surrogate, regarding the individual's health care.
"Health-care institution" means an
institution, facility, or agency licensed, certified, or otherwise authorized
or permitted by law to provide health care in the ordinary course of business.
"Health-care provider" means an
individual licensed, certified, or otherwise authorized or permitted by law to
provide health care in the ordinary course of business or practice of a
profession.
"Individual instruction" means an
individual's direction concerning a health-care decision for the individual.
"Interested persons" means the
patient's spouse, unless legally separated or estranged, a reciprocal
beneficiary, any adult child, either parent of the patient, an adult sibling or
adult grandchild of the patient, or any adult who has exhibited special care
and concern for the patient and who is familiar with the patient's personal
values.
"Person" means an individual,
corporation, business trust, estate, trust, partnership, association, joint
venture, government, governmental subdivision, agency, or instrumentality, or
any other legal or commercial entity.
"Physician" means an individual
authorized to practice medicine or osteopathy under chapter 453.
"Power of attorney for health care"
means the designation of an agent to make health-care decisions for the
individual granting the power.
"Primary physician" means a physician
designated by an individual or the individual's agent, guardian, or surrogate,
to have primary responsibility for the individual's health care or, in the
absence of a designation or if the designated physician is not reasonably
available, a physician who undertakes the responsibility.
"Reasonably available" means able to
be contacted with a level of diligence appropriate to the seriousness and
urgency of a patient's health care needs, and willing and able to act in a
timely manner considering the urgency of the patient's health care needs.
"State" means a state of the United
States, the District of Columbia, the Commonwealth of Puerto Rico, or a
territory or insular possession subject to the jurisdiction of the United
States.
"Supervising health-care provider"
means the primary physician or the physician's designee, or the health-care
provider or the provider's designee who has undertaken primary responsibility
for an individual's health care.
"Surrogate" means an individual,
other than a patient's agent or guardian, authorized under this chapter to make
a health-care decision or to act as a medicaid authorized representative for
the patient.
[L 1999, c 169, pt of §1; am L 2004, c 161, §3; am L 2009, c 11,
§40; am L 2018, c 125, §2]
HRS §327E-3 Advance health-care directives
327E-3. Advance health-care directives
(a) An adult or emancipated minor may give an individual instruction. The instruction may be oral or written. The instruction may be limited to take effect only if a specified condition arises.
(b) An adult or emancipated minor may execute
a power of attorney for health care, which may authorize the agent to make any
health-care decision the principal could have made while having capacity. The
power remains in effect notwithstanding the principal's later incapacity and
may include individual instructions. Unless related to the principal by blood,
marriage, or adoption, an agent may not be an owner, operator, or employee of
the health-care institution at which the principal is receiving care. The
power shall be in writing, contain the date of its execution, be signed by the
principal, and be witnessed by one of the following methods:
(1) Signed by at least two individuals, each of whom
witnessed either the signing of the instrument by the principal or the
principal's acknowledgment of the signature of the instrument; or
(2) Acknowledged before a notary public at any place
within this State.
(c) A witness for a power of attorney for
health care shall not be:
(1) A health-care provider;
(2) An employee of a health-care provider or
facility; or
(3) The agent.
(d) At least one of the individuals used as a
witness for a power of attorney for health care shall be someone who is
neither:
(1) Related to the principal by blood, marriage, or
adoption; nor
(2) Entitled to any portion of the estate of the
principal upon the principal's death under any will or codicil thereto of the
principal existing at the time of execution of the power of attorney for health
care or by operation of law then existing.
(e) Unless otherwise specified in a power of
attorney for health care, the authority of an agent becomes effective only upon
a determination that the principal lacks capacity, and ceases to be effective
upon a determination that the principal has recovered capacity.
(f) Unless otherwise specified in a written
advance health-care directive, a determination that an individual lacks or has
recovered capacity, or that another condition exists that affects an individual
instruction or the authority of an agent, shall be made by the primary
physician.
(g) An agent shall make a health-care decision
in accordance with the principal's individual instructions, if any, and other
wishes to the extent known to the agent. Otherwise, the agent shall make the
decision in accordance with the agent's determination of the principal's best
interest. In determining the principal's best interest, the agent shall
consider the principal's personal values to the extent known to the agent.
(h) A health-care decision made by an agent
for a principal shall be effective without judicial approval.
(i) A written advance health-care directive
may include the individual's nomination of a guardian.
(j) An advance health-care directive shall be
valid for purposes of this chapter if it complies with this chapter, or if it
was executed in compliance with the laws of the state where it was executed.
[L
1999, c 169, pt of §1; am L 2004, c 161, §36]
HRS §327E-4 Revocation of advance health-care directive
327E-4. Revocation of advance health-care directive
(a) An individual may revoke the designation of an agent only by a signed writing or by personally informing the supervising health-care provider.
(b) An individual may revoke all or part of an
advance health-care directive, other than the designation of an agent, at any
time and in any manner that communicates an intent to revoke.
(c) A health-care provider, agent, guardian,
or surrogate who is informed of a revocation shall promptly communicate the
fact of the revocation to the supervising health-care provider and to any
health-care institution at which the patient is receiving care.
(d) A decree of annulment, divorce,
dissolution of marriage, or legal separation revokes a previous designation of
a spouse as agent unless otherwise specified in the decree or in a power of
attorney for health care.
(e) An advance health-care directive that
conflicts with an earlier advance health-care directive revokes the earlier
directive to the extent of the conflict.
[L 1999, c 169, pt of §1]
HRS §327E-5 Health-care decisions; surrogates
327E-5. Health-care decisions; surrogates
(a) A patient may designate or disqualify any individual to act as a surrogate by personally informing the supervising health-care provider. In the absence of such a designation, or if the designee is not reasonably available, a surrogate may be appointed to make a health-care decision for the patient.
(b) A surrogate may make a health-care
decision for a patient who is an adult or emancipated minor if the patient has
been determined by the primary physician to lack capacity and no agent or
guardian has been appointed or the agent or guardian is not reasonably
available. Upon a determination that a patient lacks decisional capacity to
provide informed consent to or refusal of medical treatment, the primary
physician or the physician's designee shall make reasonable efforts to notify
the patient of the patient's lack of capacity. The primary physician, or the
physician's designee, shall make reasonable efforts to locate as many
interested persons as practicable, and the primary physician may rely on such
individuals to notify other family members or interested persons.
(c) Upon locating interested persons, the
primary physician, or the physician's designee, shall inform such persons of
the patient's lack of decisional capacity and that a surrogate decision-maker
should be selected for the patient.
(d) Interested persons shall make reasonable
efforts to reach a consensus as to who among them shall make health-care
decisions on behalf of the patient. The person selected to act as the
patient's surrogate should be the person who has a close relationship with the
patient and who is the most likely to be currently informed of the patient's
wishes regarding health-care decisions. If any of the interested persons
disagrees with the selection or the decision of the surrogate, or, if after
reasonable efforts the interested persons are unable to reach a consensus as to
who should act as the surrogate decision-maker, then any of the interested
persons may seek guardianship of the patient by initiating guardianship
proceedings pursuant to chapter 551 or chapter 560, as applicable. Only
interested persons involved in the discussions to choose a surrogate may
initiate such proceedings with regard to the patient.
(e) If any interested person, the guardian, or
primary physician believes the patient has regained decisional capacity, the
primary physician shall reexamine the patient and determine whether or not the
patient has regained decisional capacity and shall enter a decision and the
basis for such decision into the patient's medical record and shall notify the
patient, the surrogate decision-maker, and the person who initiated the
redetermination of decisional capacity.
(f) A surrogate who has been designated by the
patient may make health-care decisions for the patient that the patient could
make on the patient's own behalf.
(g) A surrogate who has not been designated by
the patient may make all health-care decisions for the patient that the patient
could make on the patient's own behalf, except that artificial nutrition and
hydration may be withheld or withdrawn for a patient upon a decision of the
surrogate only when the primary physician and a second independent physician
certify in the patient's medical records that the provision or continuation of
artificial nutrition or hydration is merely prolonging the act of dying and the
patient is highly unlikely to have any neurological response in the future.
The surrogate who has not been designated by
the patient shall make health-care decisions for the patient based on the
wishes of the patient, or, if the wishes of the patient are unknown or unclear,
on the patient's best interest.
The decision of a surrogate who has not been
designated by the patient regarding whether life-sustaining procedures should
be provided, withheld, or withdrawn shall not be based, in whole or in part, on
either a patient's preexisting, long-term mental or physical disability, or a
patient's economic status. A surrogate who has not been designated by the
patient shall inform the patient, to the extent possible, of the proposed
procedure and the fact that someone else is authorized to make a decision regarding
that procedure.
(h) A health-care decision made by a surrogate
for a patient is effective without judicial approval.
(i) A surrogate may act as a medicaid
authorized representative, pursuant to federal and state medicaid laws relating
to authorized representatives, on the patient's behalf for the purposes of
medicaid, including but not limited to assisting with, submitting, and
executing a medicaid application, redetermination of eligibility, and other
on-going medicaid-related communications with the department of human
services. For the purposes of medicaid, the surrogate may access medicaid
records of the patient on whose behalf the surrogate was designated to act.
For a surrogate to be able to act under this subsection, the surrogate shall
agree to be legally bound by the federal and state authorities related to
authorized representatives, including but not limited to maintaining the
confidentiality of any information provided by the department of human
services, in compliance with all state and federal confidentiality laws. The
surrogate's status as an authorized representative for the purposes of medicaid
shall terminate when revoked by a patient who no longer lacks decisional
capacity, upon appointment or availability of an agent or guardian of the
person, or upon the patient's death.
(j) A supervising health-care provider shall
require a surrogate to provide a written declaration under the penalty of false
swearing stating facts and circumstances reasonably sufficient to establish the
claimed authority.
[L 1999, c 169, pt of §1; am L 2018, c 125, §3]
HRS §327E-6 Decisions by guardian
327E-6. Decisions by guardian
(a) A guardian shall comply with the ward's individual instructions and shall not revoke the ward's pre-incapacity advance health-care directive unless expressly authorized by a court.
(b) Absent a court order to the contrary, a
health-care decision of a guardian appointed pursuant to chapter 560 takes
precedence over that of an agent.
(c) A health-care decision made by a guardian
for the ward is effective without judicial approval.
[L 1999, c 169, pt of §1;
am L 2004, c 161, §4]
HRS §327E-7 Obligations of health-care provider
327E-7. Obligations of health-care provider
(a) Before implementing a health-care decision made for a patient, a supervising health-care provider, if possible, shall promptly communicate to the patient the decision made and the identity of the person making the decision.
(b) A supervising health-care provider who
knows of the existence of an advance health-care directive, a revocation of an
advance health-care directive, or a designation or disqualification of a
surrogate, shall promptly record its existence in the patient's health-care
record and, if it is in writing, shall request a copy and if one is furnished
shall arrange for its maintenance in the health-care record.
(c) A supervising health-care provider who
makes or is informed of a determination that a patient lacks or has recovered
capacity, or that another condition exists which affects an individual
instruction or the authority of an agent, guardian, or surrogate, shall
promptly record the determination in the patient's health-care record and
communicate the determination to the patient, if possible, and to any person
then authorized to make health-care decisions for the patient.
(d) Except as provided in subsections (e) and
(f), a health-care provider or institution providing care to a patient shall:
(1) Comply with an individual instruction of the
patient and with a reasonable interpretation of that instruction made by a
person then authorized to make health-care decisions for the patient; and
(2) Comply with a health-care decision for the
patient made by a person then authorized to make health-care decisions for the
patient to the same extent as if the decision had been made by the patient
while having capacity.
(e) A health-care provider may decline to
comply with an individual instruction or health-care decision for reasons of
conscience. A health-care institution may decline to comply with an individual
instruction or health-care decision if the instruction or decision is contrary
to a policy of the institution which is expressly based on reasons of
conscience and if the policy was timely communicated to the patient or to a
person then authorized to make health-care decisions for the patient.
(f) A health-care provider or institution may
decline to comply with an individual instruction or health-care decision that
requires medically ineffective health care or health care contrary to generally
accepted health-care standards applicable to the health-care provider or
institution.
(g) A health-care provider or institution that
declines to comply with an individual instruction or health-care decision
shall:
(1) Promptly so inform the patient, if possible, and
any person then authorized to make health-care decisions for the patient;
(2) Provide continuing care to the patient until a
transfer can be effected; and
(3) Unless the patient or person then authorized to
make health-care decisions for the patient refuses assistance, immediately make
all reasonable efforts to assist in the transfer of the patient to another
health-care provider or institution that is willing to comply with the
instruction or decision.
(h) A health-care provider or institution may
not require or prohibit the execution or revocation of [an] advance health-care
directive as a condition for providing health care.
[L 1999, c 169, pt of §1]
HRS §327E-8 Health-care information
327E-8. Health-care information
Unless otherwise specified in an advance health-care directive, a person then authorized to make health-care decisions for a patient has the same rights as the patient to request, receive, examine, copy, and consent to the disclosure of medical or any other health-care information.
[L 1999, c 169, pt of §1]
HRS §327E-9 Immunities
327E-9. Immunities
(a) A health-care provider or institution acting in good faith and in accordance with generally accepted health-care standards applicable to the health-care provider or institution shall not be subject to civil or criminal liability or to discipline for unprofessional conduct for:
(1) Complying with a health-care decision of a person
apparently having authority to make a health-care decision for a patient,
including a decision to withhold or withdraw health care;
(2) Declining to comply with a health-care decision
of a person based on a belief that the person then lacked authority; or
(3) Complying with an advance health-care directive
and assuming that the directive was valid when made and has not been revoked or
terminated.
(b) An individual acting as agent, guardian,
or surrogate under this chapter shall not be subject to civil or criminal
liability or to discipline for unprofessional conduct for health-care decisions
made in good faith.
[L 1999, c 169, pt of §1]
HRS §327E-10 Statutory damages
327E-10. Statutory damages
(a) A health-care provider or institution that intentionally violates this chapter shall be subject to liability to the individual or the individual's estate for damages of $500 or actual damages resulting from the violation, whichever is greater, plus reasonable attorney's fees.
(b) A person who intentionally falsifies,
forges, conceals, defaces, or obliterates an individual's advance health-care
directive or a revocation of an advance health-care directive without the
individual's consent, or who coerces or fraudulently induces an individual to
give, revoke, or not to give an advance health-care directive, shall be subject
to liability to that individual for damages of $2,500 or actual damages
resulting from the action, whichever is greater, plus reasonable attorney's
fees.
[L 1999, c 169, pt of §1]
HRS §327E-11 Capacity
327E-11. Capacity
(a) This chapter does not affect the right of an individual to make health-care decisions while having capacity to do so.
(b) An individual is presumed to have capacity
to make a health-care decision, to give or revoke an advance health-care
directive, and to designate or disqualify a surrogate.
[L 1999, c 169, pt of
§1]
HRS §327E-12 Effect of copy
327E-12. Effect of copy
A copy of a written advance health-care directive, revocation of an advance health-care directive, or designation or disqualification of a surrogate has the same effect as the original.
L 1999, c 169, pt of §1
HRS §327E-13 Effect of this chapter
327E-13. Effect of this chapter
(a) This chapter shall not create a presumption concerning the intention of an individual who has not made or who has revoked an advance health-care directive.
(b) Death resulting from the withholding or
withdrawal of health care in accordance with this chapter shall not for any
purpose constitute a suicide or homicide or legally impair or invalidate a
policy of insurance or an annuity providing a death benefit, notwithstanding
any term of the policy or annuity to the contrary.
(c) This chapter shall not authorize mercy
killing, assisted suicide, euthanasia, or the provision, withholding, or
withdrawal of health care, to the extent prohibited by other statutes of this
State; provided that this subsection shall not apply to actions taken under
chapter 327L.
(d) This chapter shall not authorize or
require a health-care provider or institution to provide health care contrary
to generally accepted health-care standards applicable to the health-care
provider or institution.
(e) This chapter shall not authorize an agent
or surrogate to consent to the admission of an individual to a psychiatric
facility as defined in chapter 334, unless the individual's written advance
health-care directive expressly so provides.
(f) This chapter shall not affect other
statutes of this State governing treatment for mental illness of an individual
involuntarily committed to a psychiatric facility.
[L 1999, c 169, pt of §1; am
L 2000, c 42, §1; am L 2018, c 2, §4]
HRS §327E-14 Judicial relief
327E-14. Judicial relief
On petition of a patient, the patient's agent, guardian, or surrogate, or a health-care provider or institution involved with the patient's care, any court of competent jurisdiction may enjoin or direct a health-care decision or order other equitable relief. A proceeding under this section shall be governed by part 3 of article V of chapter 560.
[L 1999, c 169, pt of §1]
HRS §327E-15 Uniformity of application and construction
327E-15. Uniformity of application and construction
This chapter shall be applied and construed to effectuate its general purpose to make uniform the law with respect to the subject of this chapter among states enacting it.
L 1999, c 169, pt of §1
HRS §327E-16 Optional form
327E-16. Optional form
The following sample form may be used to create an advance health-care directive. This form may be duplicated. This form may be modified to suit the needs of the person, or a completely different form may be used that contains the substance of the following form.
"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:
(1) Consent or refuse consent to any care, treatment,
service, or procedure to maintain, diagnose, or otherwise affect a physical or
mental condition;
(2) Select or discharge health-care providers and
institutions;
(3) Approve or disapprove diagnostic tests, surgical
procedures, programs of medication, and orders not to resuscitate; and
(4) 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 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
(1) DESIGNATION OF AGENT: I designate the
following individual as my agent to make 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 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 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 health-care decisions for me, including decisions to provide,
withhold, or withdraw artificial nutrition and hydration, and all other forms
of health care to keep me alive, 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 primary physician determines
that I am unable to make my own health-care decisions unless I mark the
following box. If I mark this box [ ], my agent's authority to make
health-care decisions for me takes effect immediately.
(4) AGENT'S OBLIGATION: My agent shall make
health-care decisions for me in accordance with this power of attorney for
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 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 2
INSTRUCTIONS
FOR HEALTH CARE
If you are satisfied to allow your agent to
determine what is best for you in making end-of-life decisions, 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) END-OF-LIFE DECISIONS: I direct that my
health-care providers and others involved in my care provide, withhold, or
withdraw treatment in accordance with the choice I have marked below: (Check
only one box.)
[ ] (a) 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, OR
[ ] (b) Choice To Prolong Life
I want my life to be
prolonged as long as possible within the limits of generally accepted
health-care standards.
(7) ARTIFICIAL NUTRITION AND HYDRATION:
Artificial nutrition and hydration must be provided, withheld or withdrawn in
accordance with the choice I have made in paragraph (6) unless I mark the
following box. If I mark this box [ ], artificial nutrition and hydration
must be provided regardless of my condition and regardless of the choice I have
made in paragraph (6).
(8) RELIEF FROM PAIN: If I mark this box [
], I direct that treatment to alleviate pain or discomfort should be provided
to me even if it hastens my death.
(9) 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 3
DONATION OF
ORGANS AT DEATH
(OPTIONAL)
(10) Upon my death: (mark applicable box)
[ ] (a) I give any needed organs, tissues, or
parts,
OR
[ ] (b) I give the following organs, tissues, or
parts only
__________________________________________
[ ] (c) My gift is for the following purposes
(strike any of the following you do not want)
(i) Transplant
(ii) Therapy
(iii) Research
(iv) Education
PART 4
PRIMARY
PHYSICIAN
(OPTIONAL)
(11) I designate the following physician as my
primary physician:
___________________________________________________
(name of physician)
___________________________________________________
(address) (city) (state) (zip code)
___________________________________________________
(phone)
OPTIONAL: If the physician I have designated
above is not willing, able, or reasonably available to act as my primary
physician, I designate the following physician as my primary physician:
___________________________________________________
(name of physician)
___________________________________________________
(address) (city) (state) (zip
code)
___________________________________________________
(phone)
(12) EFFECT OF COPY: A copy of this form has
the same effect as the original.
(13) SIGNATURES: Sign and date the form here:
_______________________ _______________________
(date) (sign your name)
_______________________ _______________________
(address) (print your name)
_______________________
(city) (state)
(14) WITNESSES: This power of attorney will
not be valid for making 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.
ALTERNATIVE
NO. 1
Witness
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) (signature of
witness)
_______________________ _______________________
(address) (printed name of
witness)
_______________________
(city) (state)
Witness
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.
_______________________ _______________________
(date) (signature of
witness)
_______________________ _______________________
(address) (printed name of
witness)
_______________________
(city) (state)
ALTERNATIVE
NO. 2
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 1999, c 169, pt of §1; am L 2004, c 161, §36]
Source: Hawaii State Legislature (capitol.hawaii.gov), via Internet Archive capturesURL: http://www.capitol.hawaii.gov/hrscurrent/Vol06_Ch0321-0344/HRS0327E/HRS_0327E-.htmFetched: 11/10/2026