An Advance Directive (AD) is a written statement about your future medical care. It is a gift to family members and friends so that they won't have to guess what you want if you no longer can speak for yourself.
NEW: A writable PDF file of the Advance Directive form now available.
In this writable version of a PDF file you can fill out many of the fields in your computer, making it easier to read. (Please note: some fields need to be initialed or signed by you or your witnesses and are not writable in a computer.)
Aug. 2012 Revised Booklet: Your Advance Directive for Future Healthcare explained
An additional two page check list to help complete an Advance Directive, explaining the terms used and hopefully answer questions.
Why do I need an Advance Directive?
Medical technology makes it possible for patients with little or no hope of recovery to be kept alive for months or even years. This makes it important for you to discuss what kind of care you want before illness occurs.
Now is the time to talk about these important issues, while you can still make your own decisions and have time to talk about them with others. If you don't have an advance directive, and even one person interested in your care disagrees, your doctor may not honor your wishes for end of life care.
What do I put in my advance directives?
The kind of medical treatment you want or don't want.
You can say whether or not you want to be kept alive by machines that breathe for you or feed you even if there is no hope you'll get better.
The person you want to make decisions for you when you cannot.
This person (or agent) does not have to be an attorney. Unless you limit your agent's authority, your agent has the right to accept or refuse any kind of medical care and testing, discharge or select doctors, and see all medical records.
Your wishes for comfort care.
You can indicate whether you want medicine for pain or where you want to spend your last days. You can also give spiritual, ethical and religious instructions.
How can I ensure that my advance directive is honored?
Share copies and talk with people who will be involved in your care. Ask your doctor to make your advance directive part of your medical records.
Instructions for advance health care directives
Complete parts 1 and 2 on the downloaded Advance Directive form. You may add pages and make any changes you wish. You do not need an attorney to complete this form. If you need more help, you may contact the following resources for assistance.
|Kauai: Seniors Law Program||808-246-8868|
Legal Aid Society: Maui
|Oahu: UH Elder Law Program www.hawaii.edu/uhelp||808-956-6544|
|Big Island: Legal Aid Society www.legalaidhawaii.org
Part 1 - Individual Instruction
Give instructions to your doctor and others about any aspect of your health care. You will be given choices. Check only one box in each category and cross out all which do not apply.
Part 2 - Health Care Power of Attorney
Select one or more persons to be your agent and make health care decisions if you are unable. The person you appoint can be a spouse, adult child, friend or any other trusted person. Your agent cannot be an owner or employee of a health care facility unless they are related to you.
Ask 2 witnesses to sign and date the form
Both must be people you know. They cannot be health care providers (like a doctor, nurse or social worker), employees of a health care facility, or the person you choose as an agent. One of the two persons cannot be related to you or have inheritance rights.
- Or -
If you do not have 2 witnesses, your advance directive must be notarized.
When you have completed your advance directive
Download a Free Advance Directive (pdf file, 2 pages)