Fillable Hawaii Advance Health Care Directive (Page 3 of 8) in pdf

Hawaii Advance Health Care Directive Page 3

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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 of my person 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-

Hawaii Advance Health Care Directive Page 3

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