Youarenotrequiredtofilloutanypartofthis Willtolive Oranyother Document

SUGGESTIONS

FORPREPARINGWILLTOLIVEDURABLEPOWEROFATTORNEY

(Pleasereadthedocumentitselfbeforereadingthis.Itwillhelpyoubetterunderstand thesuggestions.)

YOUARENOTREQUIREDTOFILLOUTANYPARTOFTHIS"WILLTOLIVE"ORANYOTHER DOCUMENT SUCHASALIVINGWILLORDURABLEPOWER OFATTORNEYFORHEALTHCARE. NOONEMAYFORCEYOUTOSIGNTHISDOCUMENTORANYOTHER OFITSKIND.

TheWilltoLiveformstartsfromtheprinciplethatthepresumptionshouldbeforlife. Ifyousignitwithoutwritingany"SPECIALCONDITIONS,"youaregivingdirectionstoyourhealthcareprovider(s)andhealthcareagent1todotheirbesttopreserveyourlife.

Somepeoplemaywishtocontinuecertaintypesofmedicaltreatmentwhentheyareterminallyillandinthefinalstagesoflife. Othersmaynot.

Ifyouwishtorefusesomespecificmedicaltreatment,theWilltoLiveformprovidesspacetodoso("SPECIALCONDITIONS"). Youmaymakespecialconditionsforyourtreatmentwhenyourdeathisimminent,meaningyouwilllivenomorethanaweekevenifgivenallavailablemedicaltreatment;orwhenyouareincurablyterminallyill,meaningyouwilllive

nomorethanthreemonthsevenifgivenallavailablemedicaltreatment. Thereisalsospaceforyoutowritedownspecialconditionsforcircumstancesyoudescribeyourself.

Theimportantthingforyoutorememberifyouchoosetofilloutanypartofthe"SPECIALCONDITIONS"sectionsoftheWilltoLiveisthatyoumustbeveryspecificinlistingwhattreatmentsyoudonotwant. Someexamplesofhowtobespecificwillbegivenshortly,oryoumayaskyourphysicianwhattypesoftreatmentmightbeexpectedinyourspecificcase.

Whyisitimportanttobespecific? Because,giventhepro-euthanasiaviewswidespreadinsocietyandparticularlyamongmany(notall)healthcareproviders,thereisgreatdangerthatavaguedescriptionofwhatyoudonotwantwillbemisunderstoodordistortedsoastodenyyoutreatmentthatyoudowant.

Manyinthemedicalprofessionaswellasinthecourtsarenowsocommittedtothequalityoflifeethicthattheytakeasagiventhatpatientswithseveredisabilitiesarebetteroffdeadandwouldprefernottoreceiveeitherlife-savingmeasuresornutritionandhydration.So

1Somestatesusetheterms“attorneyinfact,”“surrogate,”“designee,”and“representative”insteadof“agent.” Theyaresynonymousforpurposesofthesesuggestions.

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pervasiveisthis"consensus"thatitisaccuratetosaythatinpracticeitisnolongertruethatthe"presumptionisforlife"butratherfordeath. Inotherwords,insteadofassumingthatanowincompetentpatientwouldwanttoreceivetreatmentandcareintheabsenceofclearevidencetothecontrary,theassumptionhasvirtuallybecomethatsinceany"reasonable"personwouldwanttoexercisea"righttodie,"treatmentandcareshouldbewithheldorwithdrawnunlessthereisevidencetothecontrary. TheWilltoLiveisintendedtomaximizethechanceofprovidingthatevidence.

Itisimportanttorememberthatyouarewritingalegaldocument,notholdingaconversation,andnotwritingamoraltextbook. Thelanguageyouorareligiousormoralleadermightuseindiscussingwhatisandisnotmoraltorefuseis,fromalegalstandpoint,oftenmuchtoovague. Therefore,itissubjecttomisunderstandingordeliberateabuse.

Thepersonyouappointasyourhealthcareagentmayunderstandgeneraltermsinthesamewayyoudo. Butrememberthatthepersonyouappointmaydie,orbecomeincapacitated,orsimplybeunavailablewhendecisionsmustbemadeaboutyourhealthcare. Ifanyofthesehappens,acourtmightappointsomeoneelseyoudon'tknowinthatperson'splace. Alsorememberthatsincetheagenthastofollowtheinstructionsyouwriteinthisform,ahealthcareprovidercouldtrytopersuadeacourtthattheagentisn'treallyfollowingyourwishes. Acourtcouldoverruleyouragent'sinsistenceontreatmentincasesinwhichthecourtinterpretsanyvaguelanguageyouputinyour"WilltoLive"lessprotectivelythanyoumeantit.

So,forexample,donotsimplysayyoudon'twant"extraordinarytreatment." Whateverthevalueofthatlanguageinmoraldiscussions,thereissomuchdebateoverwhatitmeanslegallythatitcouldbeinterpretedverybroadlybyadoctororacourt. Forinstance,itmightbeinterpretedtorequirestarvingyoutodeathwhenyouhaveadisability,evenifyouareinnodangerofdeathifyouarefed.

Forthesamereason,donotuselanguagerejectingtreatmentwhichhasaphraselike"excessivepain,expenseorotherexcessiveburden."Doctorsandcourtsmayhaveaverydifferentdefinitionofwhatis"excessive"ora"burden"thanyoudo. Donotuselanguagethatrejectstreatmentthat"doesnotofferareasonablehopeofbenefit.""Benefit"isalegallyvagueterm.Ifyouhadasignificantdisability,ahealthcareproviderorcourtmightthinkyouwouldwantnomedicaltreatmentatall,sincemanydoctorsandjudgesunfortunatelybelievethereisno"benefit"tolifewithaseveredisability.

Whatsortoflanguageisspecificenoughifyouwishtowriteexclusions? Herearesomeexamplesofthingsyoumight--ormightnot--wanttolistunderoneormoreofthe"SpecialConditions"describedontheform. RememberthatanyofthesewillpreventtreatmentONLYunderthecircumstances--suchaswhendeathisimminent--describedinthe"SpecialCondition"youlistitunder. (Theexamplesarenotmeanttobeallinclusive--justsamplesofthetypeofthingyoumightwanttowrite.)

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"Cardiopulmonaryresuscitation(CPR)."(IfyouwouldlikeCPRinsomebutnotallcircumstanceswhenyouareterminallyill,youshouldtrytobestillmorespecific:forexample,youmightwrite"CPRifcardiopulmonaryarresthasbeencausedbymyterminalillnessoracomplicationofit."ThiswouldmeanthatyouwouldstillgetCPRif,forexample,youwerethevictimofsmokeinhalationinafire.) "Organtransplants." (Again,youcouldbestillmorespecific,rejecting,forexample,justa"hearttransplant.")

"Surgerythatwouldnotcureme,wouldnotimproveeithermymentalormyphysicalcondition,wouldnotmakememorecomfortable,andwouldnothelpmetohavelesspain,butwouldonlykeepmealivelonger."

"Atreatmentthatwillitselfcausemesevere,intractable,andlong-lastingpainbutwillnotcureme."

PainRelief

Underthe"GeneralPresumptionforLife,"ofyourWilltoLive,youwillbegivenmedicationnecessarytocontrolanypainyoumayhave"aslongasthemedicationisnotusedinordertocausemydeath." Thismeansthatyoumaybegivenpainmedicationthathasthesecondary,butunintended,effectofshorteningyourlife. Ifthisisnotyourwish,youmaywanttowritesomethinglikeoneofthefollowingunderthethirdsetof"SpecialConditions"(thesectionforconditionsyoudescribeyourself):

"Iwouldlikemedicationtorelievemypainbutonlytotheextentthemedicationwouldnotseriouslythreatentoshortenmylife."OR

"Iwouldlikemedicationtorelievemypainbutonlytotheextentitisknown,toareasonablemedicalcertainty,thatitwillnotshortenmylife."

Thinkcarefullyaboutanyspecialconditionsyoudecidetowriteinyour"WilltoLive."Youmaywanttoshowthemtoyourintendedagentandacoupleofotherpeopletoseeiftheyfindthemclearandiftheymeanthesamethingtothemastheymeantoyou. Rememberthathowcarefullyyouwritemayliterallybeamatteroflifeordeath--yourown.

AFTER WRITINGDOWNYOURSPECIAL CONDITIONS,IFANY,YOUSHOULDMARKOUTTHERESTOFTHEBLANKLINESLEFT ONTHEFORM FORTHEM (JUSTASYOUDOAFTER

WRITING OUTTHEAMOUNTONACHECK)TOPREVENT ANYDANGERTHATSOMEBODYOTHERTHANYOUCOULDWRITE INSOMETHING ELSE.

ITISWISETOREVIEW YOURWILL TOLIVEPERIODICALLYTOENSURETHATITSTILLGIVESTHEDIRECTIONSYOUWANTFOLLOWED.

RobertPowellCenterforMedicalEthics

NationalRighttoLife

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HowtousetheHawaiiWilltoLiveForm

SUGGESTIONS ANDREQUIREMENTS

1.Thisdocumentallowsyoutodesignate(name)ahealthcareagent-someone(whodoesnothavetobealawyer)whowillmakehealthcaredecisionsforyouwheneveryouareunabletomakethemforyourself. Italsoallowsyoutogiveinstructionsconcerningmedicaltreatmentdecisionsthatthehealthcareagentmustfollow. Anypersonwhoisatleast18yearsoldortotallyself-supportingmaydesignateahealthcareagentthroughthisdocument.

2.Toexecuteavalidpowerofattorney,youmustsignanddatethisdocument,whichmustbewitnessedinoneoftwoways:

A.)Signedbyatleasttwoindividuals,eachofwhomwitnessedeitheryoursigningofthedocumentoryouracknowledgmentofthesignatureofthedocument(ifsomeonesignedthedocumentforyouinyourpresencebecauseyouwereunabletodoso);OR

B.)Acknowledgedbeforeanotarypublicatanyplacewithinthisstate.

3.Awitnesscannotbe:(1)ahealth-careprovider;(2)anemployeeofahealth-careproviderorfacility;or(2)thedesignatedagent.Atleastoneoftheindividualsusedasawitnessforapowerofattorneyforhealthcarecannotbe:(1)relatedtoyoubyblood,marriage,oradoption;or(2)entitledtoanyportionofyourestateuponyourdeathunderanywillordocumentexistingatthetimeofexecutionofthisdocumentorbyoperationoflawthenexisting.

4.Itishelpfultodesignatesuccessorhealthcareagent(s)totakeoverifyourfirstchoiceisunabletoserve. Thereisspaceonthisformforyoutodesignatetwosuccessoragent(s).

5.Youshouldtellyourdoctoraboutthisdocument.Youshouldalsoaskyourdoctortokeepacopyofthisdocumentasapartofyourmedicalhealthrecord.

6.Yourhealthcareagent’sauthoritytakeseffectonlywhenyounolongerhavethecapacitytomakeandcommunicateyourownhealthcaredecisions.

7.Thisdocumentwillremainineffectuntilyourevoke(cancel)it. Youmayrevokethedesignationofanagentonlybyasignedwritingorbypersonallyinformingthe

supervisinghealth-careprovider.2

Youmayrevokeallorpartofthishealthcaredirective

(otherthanthedesignationofyouragent)atanytimeinanymannerthatcommunicatesanintenttorevoke.

8.ThistypeofdocumenthasbeenauthorizedbytheHawaiiHealth-CareDecisionsAct,HawaiiRev.Stat.§§327E-1to327E-16.

9.Youshouldperiodicallyreviewyourdocumenttobesureitcomplieswithyourwishes.

Beforemakingchanges,beawarethatitispossiblethatthestatutescontrollingthisdocumenthavechangedsincethisformwasprepared. ContacttheWilltoLiveProjectbyvisiting

10.Ifyouhaveanyquestionsaboutthisdocument,orwantassistanceinfillingitout,pleaseconsultanattorney.

ForadditionalcopiesoftheWilltoLive,pleasevisit

Formprepared2001

Updated2008

2UnderStatelaw,though,adecreeofannulment,divorce,dissolutionofmarriage,orlegalseparationrevokesapreviousdesignationofaspouseasyouragent,unlessthedecreespecifiesotherwise.

HawaiiPowerofAttorney forHealthCare

WilltoLiveForm

DESIGNATION OFAGENT

I,(yourname)

(youraddress)

(yourphonenumber)

designatethefollowingindividualasmyagenttomakehealth-caredecisionsforme:

(Nameofagent) (addressofagent) (phonenumber(s)ofagent)

OPTIONAL:IfIrevokemyagent’sauthority,orifmyagentisnotwilling,able,orreasonablyavailabletomakehealth-caredecisionsforme,Idesignateasmyfirstalternateagent:

FirstSuccessorAgent

(successoragent’sname)(successoragent’saddress)

(successoragent’sphonenumber)

OPTIONAL:IfIrevoketheauthorityofmyagentandfirstalternateagent,orifneitheriswilling,able,orreasonablyavailabletomakehealth-caredecisionsforme,Idesignateasmysecondalternateagent:

SecondSuccessorAgent

(secondsuccessoragent’sname)(secondsuccessoragent’saddress)

(secondsuccessoragent’sphonenumber)

WHENAGENT’SAUTHORITY BECOMESEFFECTIVE

Myagent’sauthoritybecomeseffectivewhenmyprimaryphysiciandeterminesthatIamunabletomakemyownhealth-caredecisionsunlessImarkthefollowingbox. IfImarkthisbox,myagent’sauthoritytomakehealth-caredecisionsformetakeseffectimmediately.

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Myagent’sauthoritytomakehealth-caredecisionstakeseffectimmediately.

NOMINATIONOFGUARDIAN

Intheeventacourtappointsaguardianonmybehalf,Inominatetheagentdesignatedinthisform. Ifthatagentisnotwilling,able,orreasonablyavailabletoactasguardian,InominatethealternateagentswhomIhavenamed,intheorderdesignated.

INSTRUCTIONSFORHEALTH CARE:

GENERAL PRESUMPTIONFORLIFE

Idirectmyhealthcareprovider(s)andmyhealthcareagent(s)tomakehealthcaredecisionsconsistentwithmygeneraldesirefortheuseofmedicaltreatmentthatwouldpreservemylife,aswellasfortheuseofmedicaltreatmentthatcancure,improve,reduceorpreventdeterioration

in,anyphysicalormentalcondition.

Foodandwaterarenotmedicaltreatment,butbasicnecessities. Idirectmyhealthcareprovider(s)andmyhealthcareagenttoprovidemewithfoodandfluids,orally,intravenously,bytube,orbyothermeanstothefullextentnecessarybothtopreservemylifeandtoassuremetheoptimalhealthpossible.

Idirectthatmedicationtoalleviatemypainbeprovided,aslongasthemedicationisnotusedinordertocausemydeath.

Idirectthatthefollowingbeprovided:

•theadministrationofmedication;

•cardiopulmonaryresuscitation(CPR);and

•theperformanceofallothermedicalprocedures,techniques,andtechnologies,includingsurgery,

–alltothefullextentnecessarytocorrect,reverse,oralleviatelife-threateningorhealthimpairingconditionsorcomplicationsarisingfromthoseconditions.

IalsodirectthatIbeprovidedbasicnursingcareandprocedurestoprovidecomfortcare.

Ireject,however,anytreatmentsthatuseanunbornornewbornchild,oranytissueororganofanunbornornewbornchild,whohasbeensubjecttoaninducedabortion. Thisrejectiondoesnotapplytotheuseoftissuesororgansobtainedinthecourseoftheremovalofanectopicpregnancy.

Ialsorejectanytreatmentsthatuseanorganortissueofanotherpersonobtainedinamannerthatcauses,contributesto,orhastensthatperson’sdeath.

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Irequestanddirectthatmedicaltreatmentandcarebeprovidedtometopreservemylifewithoutdiscriminationbasedonmyageorphysicalormentaldisabilityorthe“quality”ofmylife. Irejectanyactionoromissionthatisintendedtocauseorhastenmydeath.

Idirectmyhealthcareprovider(s)andmyhealthcareagenttofollowthepolicyabove,evenifI

amjudgedtobeincompetent.

DuringthetimeIamincompetent,myhealthcareagent(s)namedaboveisauthorizedtomakemedicaldecisionsonmybehalf,consistentwiththeabovepolicy,afterconsultationwithmyhealthcareprovider(s),utilizingthemostcurrentdiagnosesand/orprognosisofmymedicalcondition,inthefollowingsituationswiththewrittenspecialinstructions.

WHENMYDEATHISIMMINENT

A.IfIhaveanincurableterminalillnessorinjury,andIwilldieimminently–meaningthatareasonablyprudentphysician,knowledgeableaboutthecaseandthetreatmentpossibilitieswithrespecttothemedicalconditionsinvolved,wouldjudgethatIwillliveonlyaweekorlesseveniflifesavingtreatmentorcareisprovidedtome–thefollowingmaybewithheldorwithdrawn:(Beasspecificaspossible;SEESUGGESTIONS.):

(Crossoffanyremainingblanklines.)

WHENIAMTERMINALLYILL

B. FinalStageofTerminalCondition. IfIhaveanincurableterminalillnessorinjuryandeventhoughdeathisnotimminentIaminthefinalstageofthatterminalcondition–meaningthatareasonablyprudentphysician,knowledgeableaboutthecaseandthetreatmentpossibilitieswithrespecttothemedicalconditionsinvolved,wouldjudgethatIwillliveonlythreemonthsorless,eveniflifesavingtreatmentorcareisprovidedtome–thefollowingmaybewithheldorwithdrawn:

(Beasspecificaspossible;SEESUGGESTIONS.):

(Crossoffanyremainingblanklines.)

C. OTHER SPECIAL CONDITIONS:

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(Beasspecificaspossible;SEESUGGESTIONS.):

(Crossoffanyremainingblanklines.)

IFIAMPREGNANT

D. SpecialInstructionsforPregnancy. IfIampregnant,Idirectmyhealthcareprovider(s)andmyhealthcareagent(s)tousealllifesavingproceduresformyselfwithnoneoftheabovespecialconditionsapplyingifthereisachancethatprolongingmylifemightallowmychildtobebornalive. IalsodirectthatlifesavingproceduresbeusedevenifIamlegallydeterminedtobebraindeadifthereisachancethatdoingsomightallowmychildtobebornalive. ExceptasIspecifybywritingmysignatureintheboxbelow,nooneisauthorizedtoconsenttoanyprocedureformethatwouldresultinthedeathofmyunbornchild.

IfIampregnant,andIamnotinthefinalstageofaterminalconditionasdefinedabove,medicalproceduresrequiredtopreventmydeathareauthorizedeveniftheymayresultinthedeathofmyunbornchildprovidedeverypossibleeffortismadetopreservebothmylifeandthelifeof myunbornchild.

SignatureofDeclarant

EFFECTOFCOPY

Acopyofthisformhasthesameeffectastheoriginal.

Signedthis dayof ,20.

(Signature)

(PrintName)

WITNESSES

Thispowerofattorneywillnotbevalidformakinghealth-caredecisionsunlessitiseither(a)signedbytwoqualifiedadultwitnesseswhoarepersonallyknowntoyouandwhoarepresentwhenyousignoracknowledgeyoursignature;or(b)acknowledgedbeforeanotarypublicinthestate.

FIRSTALTERNATIVE

Ideclareunderpenaltyoffalseswearingpursuantto§710-102,HawaiiRevisedStatutes,thattheprincipalispersonallyknowntome,thattheprincipalsignedoracknowledgedthispowerofattorneyinmypresence,thattheprincipalappearstobeofsoundmindandundernoduress,

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fraud,orundueinfluence,thatIamnotthepersonappointedasagentbythisdocument,andthatIamnotahealth-careprovider,noranemployeeofahealth-careproviderorfacility. Iamnotrelatedtotheprincipalbyblood,marriage,oradoption,andtothebestofmyknowledge,Iamnotentitledtoanypartoftheestateoftheprincipaluponthedeathoftheprincipalunderawillnowexistingorbyoperationoflaw.

FirstWitnessSignature:

Date: PrintName:

Address:

Iamnotahealth-careprovider,noranemployeeofahealth-careproviderorfacility.

SecondWitnessSignature:

Date: PrintName:

Address:

SECONDALTERNATIVE

NOTARYPUBLIC

StateofHawaii

Countyof

Onthis dayof ,20 ,beforeme(nameofnotarypublic)

,personallyknowntobe(orprovedtomeonthebasisofsatisfactoryevidence)tobethepersonwhosenameissubscribedtothisinstrument,andacknowledgedthatheorsheexecutedit.

NotarySeal

SignatureofNotaryPublic

Mycommissionexpires:

Formprepared2001

Updated2008

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