Hawaii Living Will Template
This Living Will is designed to be in compliance with the Hawaii Uniform Health-Care Decisions Act (Chapter 327E of the Hawaii Revised Statutes). It helps to ensure that your health care wishes are known and considered in the event that you are unable to communicate them yourself.
Please provide the following information:
Full Name: ___________________________________________________
Date of Birth: ________________________________________________
Address: _____________________________________________________
City: ________________________State: HI Zip Code: ___________
Primary Phone: _______________________________________________
Email Address: _______________________________________________
Declaration
I, ________________________________________ [your name], being of sound mind, willfully and voluntarily make known my desires that my dying shall not be artificially prolonged under the circumstances set forth below, and I do hereby declare:
- If, in the judgment of my attending physician, I am suffering from a terminal condition, and I am unable to communicate my health care decisions due to incapacity, I direct that life-sustaining treatment be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication or the performance of any medical procedure deemed necessary to provide me with comfortable care.
- In the absence of my ability to give directions regarding the use of life-sustaining treatment, it is my intention that this directive shall be honored by my family and physicians as the final expression of my legal right to refuse medical or surgical treatment and accept the consequences of such refusal.
- I designate the following person as my health care agent to make any health care decisions for me, if I am unable to make such decisions for myself:
Agent's Full Name: _________________________________________
Agent's Relationship: _____________________________________
Agent's Primary Phone: ______________________________________
Agent's Alternate Phone: ____________________________________
- If the person named as my agent is not available, or is unable or unwilling to act as my agent, then I designate the following person as my alternate agent:
Alternate Agent's Full Name: _________________________________
Alternate Agent's Relationship: _______________________________
Alternate Agent's Primary Phone: ______________________________
Alternate Agent's Alternate Phone: _____________________________
Special Instructions
In the space below, you may give special instructions limiting or extending the powers granted to your agent.
______________________________________________________________________________
______________________________________________________________________________
Signatures
This directive shall become effective immediately upon my incapacity to make my own health care decisions. I understand the full import of this directive and I am emotionally and mentally competent to make this directive.
Date: _______________________ Signature: _______________________________
Witness Declaration
I declare that the person who signed this document is personally known to me and appears to be of sound mind and under no duress, fraud, or undue influence. I am not the person appointed as agent or alternate agent by this document.
Name of Witness: _______________________________________________
Date: _______________________ Signature of Witness: ________________________