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Hawaii Living Will

DECLARATION

A. Statement of Declarant

Declaration made this _________ day of _________(month, year). I, _________, being of sound mind, and understanding that I have the right to request that my life be prolonged to the greatest extent possible, wilfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

My instructions shall prevail even if they create a conflict with the desires of my relatives, hospital policies, or the principles of those providing my care.

If I should develop a terminal condition or a permanent loss of the ability to communicate concerning medical treatment decisions, with no reasonable chance of regaining this ability, I do not want to have my life prolonged. I would not want to be subjected to surgery or resuscitation. Nor would I then wish to have life sustaining medicine or procedures. Instead, I request care, including medicine and procedures, for the purpose of providing comfort and pain relief.

CHECKLIST

I have also considered whether I want tube feeding to be provided and have selected one of the following provisions by putting a mark in the space provided:

[ ] I do NOT want my life prolonged by tube or other artificial feeding or provision of fluids by a tube if my condition is as stated above.

[ ] I DO want my life prolonged by tube or other artificial feeding and provision of fluids by a tube if my condition is as stated above.

If neither provision is selected or if both are selected, it shall be presumed that tube or other artificial feeding or provision of fluids by tube are requested to prolong the declarant's life.

This declaration shall control in all circumstances.

I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.

Signed _________

Address _________

B. Statement of Witnesses

I am at least 18 years of age and

not related to the declarant by blood, marriage, or adoption; and

not currently the attending physician, an employee of the attending physician, or an employee of the health care facility in which the declarant is a patient.

The declarant is personally known to me and I believe the declarant to be of sound mind.

Witness _________

Address _________

Witness _________

Address _________

C. Notarization

Subscribed, sworn to and acknowledged before me by _________, the declarant, and subscribed and sworn to before me by _________ and _________, witnesses, this _________ day of _________, 20__.

(SEAL) Signed _________

_______________

(Official capacity of officer)

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