Life Sustaining Statute, Hawaii

Declaration as Provided by Hawaii Revised Statutes Chapter 327D, Section 4
DECLARATION

A. Statement of Declarant

Declaration made this __________________ day of _____________, 20_______. I, _________________ being of sound mind, willfully and voluntarily make known my desire that my dying shall not be artificially prolonged under the circumstances set forth below, and do hereby declare:

If at any time I should have an incurable or irreversible condition certified to be terminal by two physicians who have personally examined me, one of whom shall be my attending physician, and the physicians have determined that I am unable to make decisions concerning my medical treatment, and that without administration of life-sustaining treatment my death will occur in a relatively short time, and where the application of life-sustaining procedures would serve only to prolong artificially the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, nourishment, or fluids or the performance of any medical procedure deemed necessary to provide me with comfort or to alleviate pain.

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

________________________________________________________________
STATE OF ____________________
COUNTY OF ___________________
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 the attending physician, an employee of the attending physician, or an employee of the medical 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_______.

 

_____________________________________
Official Capacity: _________________
Declaration as Provided by Hawaii Revised Statutes Chapter 327D, Section 4
Review List

This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Hawaii. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.

1. Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.

 

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