Hawaii Living Will Template
This Living Will template is designed to comply with the Hawaii Revised Statutes, specifically the "Uniform Health-Care Decisions Act" (Chapter 327E). It allows you to express your wishes concerning medical treatment in the event that you are unable to communicate these instructions yourself. Ensure to provide clear and direct instructions here so your healthcare provider can follow your wishes regarding life-sustaining treatment and end-of-life care.
Personal Information
Name: ___________________________________________
Date of Birth: ___________________________________
Address: ________________________________________
City: ________________ State: HI Zip Code: _________
Healthcare Directives
I, _________________________, being of sound mind, hereby direct my healthcare providers to follow the instructions outlined in this document in case I am unable to communicate my healthcare wishes. This Living Will expresses my desires regarding life-sustaining treatment, including artificial nutrition and hydration, in circumstances where my condition is terminal and recovery is not expected.
Choice Regarding Life-Sustaining Treatment
If I am in any condition described below, I direct that:
- My life should not be prolonged by life-sustaining treatment, except as described below, if I am in a terminal condition where the application of life-sustaining treatment would only serve to artificially prolong the process of dying or if I am permanently unconscious. Life-sustaining treatment includes both mechanical respiration and artificially provided nutrition and hydration.
- I want to receive the following types of life-sustaining treatment: ________________________ (for example, pain relief, antibiotics, etc.).
- Under the following conditions, I would want my life to be prolonged as long as possible: _____________________________________________________________.
Additional Instructions
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Designation of Health Care Agent
I designate the following individual as my health care agent to make health care decisions for me if I am unable to make these decisions myself. This individual has affirmed their willingness to act in this capacity and to make decisions in accordance with my wishes as stated in this Living Will.
Name: ___________________________________________
Relationship to me: ______________________________
Phone Number: ___________________________________
In the event that my primary health care agent is unable, unwilling, or unavailable to act in this capacity, I hereby designate the following individual as a successor health care agent:
Name: ___________________________________________
Relationship to me: ______________________________
Phone Number: ___________________________________
Signatures
This document is executed voluntarily and without any coercion. I understand the full import of this Living Will.
Date: ________________ Signature: _______________________________
This Living Will must be witnessed by two individuals who are not related to me, are not my heirs or beneficiaries, and do not have a financial responsibility for my healthcare.
Witness 1: ________________________________________
Address: __________________________________________
Date: ________________ Signature: _______________________________
Witness 2: ________________________________________
Address: __________________________________________
Date: ________________ Signature: _______________________________