MAKE YOUR FREE Hawaii Medical Power of Attorney

ADVANCE HEALTH-CARE DIRECTIVE

You have the right to name someone else to make health-care decisions for you. If you use this form, you may complete or modify all or any part of it. You are free to use a different form.

This form is a power of attorney for health care. It lets you name another individual as agent to make health-care decisions for you if you become incapable of making you 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 resuscitate; and

(d) Direct the provision, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care.

After completing this form, sign and date the form at the end and have the form witnessed or notarized. 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 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

. DESIGNATION OF AGENT. I, , designate the following individual as my agent to make health-care decisions for me:

NOTICE: Generally you should not appoint any of the following persons as your agent:

(1) your treating physician or health care provider;

(2) an employee of your treating physician or health care provider, unless the person is your relative;

(3) an owner, operator, or employee of your health-care institution, unless the person is your relative;

(4) your residential care provider; or

(5) an employee of your residential care provider, unless the person is your relative.

. AGENT'S AUTHORITY: My agent is authorized to make all health-care decisions for me, decisions to provide, withhold, or withdraw artificial nutrition and hydration, with the following limitations:

. 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.

. AGENT'S OBLIGATION: My agent shall make health-care decisions for me in accordance with this document 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.

. NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed to me by a court, I nominate the agent designated in this form.

PART 2 - GENERAL PROVISIONS

A. EFFECT OF COPY. A copy of this form has the same effect as the original.

B. HOLD HARMLESS. All persons or entities who in good faith endeavor to carry out the terms and provisions of this document shall not be liable to me, my estate, my heirs or assigns for any damages or claims arising because of their action or inaction based on this document, and my estate shall defend and indemnify them.

C. SEVERABILITY. If any provision of this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.

D. STATEMENT OF INTENTIONS. It is my intent that this document be legally binding and effective. If the law does not recognize this document as legally binding and effective, it is my intent that this document be taken as a formal statement of my desire concerning the method by which any health care decisions should be made on my behalf during any period in which I am unable to make such decisions.