Download the Advance Health Care Directive Form
Complete parts 1 and 2 on the Advance Health Care Directive Form. Pages may be added and changes made. An attorney is not needed to complete this form.
Part 1 – Health Care Power of Attorney
Select one or more persons to be your agent and make health care decisions if you are unable. The person appointed can be a spouse, adult child, friend, or any other trusted person. Your agent cannot be an owner or employee of a health care facility, unless they are related to you.
Ask two witnesses to sign and date the form. Both must be people you know. They cannot be health care providers (i.e. – doctor, nurse or social worker, employees of a health care facility, or the person chosen as an agent.) One of the two persons cannot be related to you or have inheritance rights.
If you do not have two witnesses, your advance health care directive must be notarized.
Part 2 – Individual Instructions
Instructions may be given to your doctor and others about any aspect of your health care. There will be choices to be made. Check only one box in each category and cross out all that do not apply.
When You Have Completed Your Advance Health Care Directive
Be sure to have it witnessed or notarized and inform your family, friends, and doctors that you have done this. Give copies of your advance health care directive to your health care agent, doctors and others who might be involved in your care. Keep a copy in a safe, easy-to-find place in your home.
For more information on Advance Health Care Directives:
University of Hawaii Elder Law Program
Kokua Mau – Hawaii Hospice and Palliative Care Organization