Fillable Hawaii Advance Health Care Directive (Page 4 of 8) in pdf

Hawaii Advance Health Care Directive Page 4

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of-life decisions, you need not fill out this part of the form. If you do fill out this part of

the form, you may strike any wording you do not want.

(6) END-OF-LIFE DECISIONS: I direct that my health-care providers and others

involved in my care provide, withhold, or withdraw treatment in accordance with the

choice I have marked below: (Check only one box.)

[ ] (a) Choice Not To Prolong Life

I do not want my life to be prolonged if (i) I have an incurable and irreversible condition

that will result in my death within a relatively short time, (ii) I become unconscious and,

to a reasonable degree of medical certainty, I will not regain consciousness, or (iii) the

likely risks and burdens of treatment would outweigh the expected benefits, OR

[ ] (b) Choice To Prolong Life

I want my life to be prolonged as long as possible within the limits of generally accepted

health-care standards.

(7) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and hydration

must be provided, withheld or withdrawn in accordance with the choice I have made in

paragraph (6) unless I mark the following box. If I mark this box [ ], artificial nutrition

and hydration must be provided regardless of my condition and regardless of the choice I

have made in paragraph (6).

(8) RELIEF FROM PAIN: If I mark this box [ ], I direct that treatment to alleviate pain or

discomfort should be provided to me even if it hastens my death.

(9) OTHER WISHES: (If you do not agree with any of the optional choices above and

wish to write your own, or if you wish to add to the instructions you have given above,

you may do so here.) I direct that:

(Add additional sheets if needed.)

PART 3

DONATION OF ORGANS AT DEATH

(OPTIONAL)

(10) Upon my death: (mark applicable box)

[ ] (a) I give any needed organs, tissues, or parts, OR

Hawaii Advance Health Care Directive Page 4

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