Hawaii Living Will Template
This Living Will is created in accordance with the laws of the State of Hawaii. It allows you to express your wishes regarding medical treatment in the event that you become unable to communicate your preferences.
Please fill in the blanks with your personal information as indicated.
Personal Information
- Name: __________________________
- Date of Birth: __________________________
- Address: __________________________
- City, State, Zip Code: __________________________
Declaration
I, __________________________, being of sound mind, voluntarily make this declaration to direct my healthcare providers regarding my medical treatment preferences.
Medical Treatment Preferences
If I am diagnosed with a terminal condition or am in a persistent vegetative state, I wish to make the following preferences known:
- I do not want my life to be prolonged by any of the following means:
- Artificial respiration
- Cardiopulmonary resuscitation (CPR)
- Dialysis
- Nutrition and hydration provided by medical means
- I wish to receive comfort care to alleviate pain and suffering.
- I would like my family to be involved in the decision-making process, as much as possible.
Appointment of Healthcare Agent
If I am unable to make my own healthcare decisions, I appoint the following person as my healthcare agent:
- Name: __________________________
- Phone Number: __________________________
- Address: __________________________
Signatures
By signing below, I affirm that I understand the purpose of this Living Will and that I am making these choices freely and voluntarily.
Signature: __________________________
Date: __________________________
Witnesses
This document must be witnessed by two individuals who are not related to me and who will not benefit from my estate.
- Witness 1: __________________________
- Witness 2: __________________________
Witnesses' Signatures:
- Witness 1 Signature: __________________________
- Witness 2 Signature: __________________________