Hawaii Living Will Template
This Living Will is created in accordance with the laws of the State of Hawaii. It outlines your wishes regarding medical treatment in the event that you become unable to communicate your preferences.
Personal Information
- Name: ___________________________
- Date of Birth: ____________________
- Address: _________________________
- City: ____________________________
- State: Hawaii
- Zip Code: ________________________
Declaration
I, the undersigned, being of sound mind, voluntarily make this declaration to provide guidance regarding my medical treatment preferences in the event I am unable to make decisions for myself.
My Wishes
If I am diagnosed with a terminal condition or am in a state of permanent unconsciousness, I do not wish for my life to be prolonged by medical treatment that would only serve to extend the dying process.
Specific Instructions
- Do not resuscitate me if my heart stops beating.
- Do not use mechanical ventilation if I am unable to breathe on my own.
- Do not administer artificial nutrition or hydration if I am in a terminal condition.
Appointment of Healthcare Representative
I hereby appoint the following person as my healthcare representative to make decisions on my behalf if I am unable to do so:
- Name: ___________________________
- Relationship: _____________________
- Phone Number: ____________________
Signatures
This Living Will is effective upon my signature below:
Signature: ___________________________
Date: _________________________________
Witness Signature: ______________________
Date: _________________________________
Witness Signature: ______________________
Date: _________________________________
Note: This document should be kept in a safe place and shared with your healthcare representative and family members.