Hawaii Durable Medical Power of Attorney Form

Hawaii Power Of Attorney document is to legally allow an appointed person, the `Agent`, to make decisions on behalf of the named principal with respects to the type of health care treatment the principal should receive. The document is in accordance with US statutes § 327E-1 to –16 and becomes effective should the patient become incapacitated where they are no longer able to themselves competently make these medical decisions. The document requires a notary or two witnesses.

How to Write

Advanced Health Care Directive

Enter principal`s details.

  • Name.
  • Address.
  • ZIP code.

Part 1: Durable Power Of Attorney

1) Designation Of Agent

Enter agent`s and alternative agent`s details.

  • Name.
  • Address.
  • ZIP code.
  • Home telephone number.
  • Work telephone number.
  • Email address.


2) Agent`s Authority

The principal must `Strike Through`  any paragraph they do not wish to be included within the agent`s authority.

Any Other Health Care Decisions

The principal must enter the details of any other health care treatment or procedures they wish too give the agent power of attorney over.


3) When Agent`s Authority Becomes Effective

Check the box to give the agent immediate power of attorney while retaining the right to choose ones own health care treatment at all time.


Part 2: Instructions For Health Care

6) End Of Life Decisions

Check relevant box to describe treatments to be withdrawn or withheld.

  • (a) Check box not to prolong life. `Strike Through` non applicable paragraphs.
  • (b) Check box to prolong life.


Artificial Nutrition

Principal must check box if artificial nutrition and hydration are to be provided.


8) Relief From Pain

Principal must check the box if relief from pain is to be provided.


9) Other wishes

The principal must enter details of any other wishes regarding their health care.


Part 3: Donation Of Organs / Body Parts (Optional)

10) Designation Of Specific Tissues / Organs Or Body Parts

Principal must  designate particular tissue/organ or body part donation specifications.

  • (a) Check box to donate ANY tissues/organs/parts.
  • (b) Check box to donate tissues/organs/parts specified here by the principal.
  • (c) Check box to select possible uses for donations, `Striking Through` any  use not required.
  • (d) Check box to give donation to the John A. Burns School Of Medicine.


11) Primary Physician/Health Care Facility (Optional)

Enter details of designate primary physician and alternative primary physician.

  • Name.
  • Address.
  • ZIP code.
  • Telephone number.


12) Preferred Health Care Facility (Optional)

Principal must enter the details of a favored health care facility.


Part 5: Religious Or Spiritual Information (Optional)

13) Identify Favored Place Of Worship

The principal must state which, if any, church or temple they are associated with.

14) Spiritual Care Provider

The principal must state the preferred  provider of their spiritual care.

  • Name of individual or group.
  • Address.
  • ZIP code.
  • Telephone number.


15) Effect Of Copy

Principal must confirm that a copy of this document is as valid as the original.

  • Printed name.
  • Signature.
  • Date.



Alternative Number 1

Details of two witnesses must be entered.

  • Printed name.
  • Signature.
  • Address.
  • Date.

Alternative Number 2

Details of a notary must be entered.

  • Date.
  • Name off notary.
  • Name of principal.
  • Signature of notary.
  • Date notary`s commission expires.