ADVANCE HEALTH CARE DIRECTIVE FORM
Date:
Your Name: Last First Middle initial
Street Address City State Zip
Part 1: INDIVIDUAL INSTRUCTIONS FOR HEALTH CARE
The following statements only apply
• if I am close to death and life support would only postpone the moment of my death OR
• if I am in an unconscious state such as an irreversible coma or a persistent vegetative state and it is unlikely that I will ever
become conscious OR
• if I have brain damage or a brain disease that makes me permanently unable to make and communicate health-care deci-
sions about myself.
(INITIAL ONLY ONE (1) CHOICE IN EACH SECTION and CROSS OUT ALL THAT DO NOT APPLY.)
A. CHOICE TO PROLONG OR NOT TO PROLONG LIFE
____ YES, I do want to have my life prolonged as long as possible within the limits of generally accepted health-care
standards that apply to my condition.
OR
____ NO, I do not want my life prolonged.
B. ARTIFICIAL NUTRITION AND HYDRATION (FOOD AND FLUIDS) BY TUBE INTO STOMACH OR VEIN
____ YES, I do want artificial nutrition and hydration.
OR
____ NO, I do not want artificial nutrition and hydration.
C. RELIEF FROM PAIN
____ YES, I do want treatment to relieve my pain or discomfort.
OR
____ NO, I do not want treatment to relieve my pain or discomfort.
D. ETHICAL, RELIGIOUS, OR SPIRITUAL INSTRUCTIONS (OPTIONAL)
Is there a church, temple, spiritual group or a special person from whom you wish to receive spiritual care?
Name: Phone
Street Address City State Zip
E. DO YOU WANT HOSPICE CARE, IF APPROPRIATE? ____ YES ____ NO
(Hospice provides physical, psychosocial, emotional, and spiritual support and counseling for the patient and his/her family.
Hospice is available in home, hospital, hospice-unit, and nursing home settings.)
F. PRIMARY CARE PHYSICIAN
Name: Phone
G. OTHER WISHES:
If you do not agree with any of the choices above or wish to add other instructions, including body and organ donation,
you may add pages. If you are or could become pregnant, consult your doctor, and consider adding special instructions
suspending or adding provisions. Remember to sign, date, witness or notarize additional pages. File a copy with:
■ Doctor copy ■ Family Copy ■ Agent Copy ■ www.myhealthdirective.com
PART 2: HEALTH-CARE POWER OF ATTORNEY AGENT’S AUTHORITY AND OBLIGATION
My agent shall make health-care decisions for me in accordance with my best interests and wishes so far as they are known.
In determining my best interest, my agent shall consider my personal values. If a guardian of my person needs to be appoint-
ed for me by a court, I nominate my agent. I designate the following individual as my agent. He/she may make all health-
care decisions for me if I am unable or unwilling to make them for myself unless I direct otherwise:
Name of Agent (Spouse, adult child, friend or other trusted person) Relationship
Street Address City State Zip
Home Phone Work Phone E-mail
If my agent is not available, I designate the following person as my alternative agent:
Name of Alternate Agent (Spouse, adult child, friend or other trusted person) Relationship
Street Address City State Zip
Home Phone Work Phone E-mail
____ My agent may make all health-care decisions for me. OR
____ My agent may make all health-care decisions for me except: ___________________________________________________________________________________
____ My agent’s authority becomes effective when my primary physician determines that I am unable to make health-care
decisions.OR
____ My agent’s authority to make health-care decisions for me takes effect immediately.
YOUR NAME: Print Your Full Name Your Signature Date
WITNESSES: CHOOSE EITHER OPTION 1 OR 2, NOT BOTH.
Important: Witnesses cannot be your health-care agent, a health-care provider or an employee of a health-care facility. One
witness cannot be a relative or have inheritance rights.
OPTION 1: WITNESSES
Witness #1 Print Name Witness Signature Date
Address City State Zip Code
Witness #2 Print Name Witness Signature Date
Address City State Zip Code
OPTION 2: Notary Public
State of Hawai‘i, _____________ (County)
On this _______ day of ___________, in the year _______, before me, ______________________________, (insert name of
notary public) appeared ______________________________, personally known to me (or proved to me on the basis of satis-
factory evidence) to be the person whose name is subscribed to this instrument and acknowledged that he or she executed it.
My Commission Expires:______________
A copy has the same effect as the original. State of Hawai‘i – Revised September 2003.
Developed by the Executive Office on Aging,
