This is a required section in which the Declarant (the person the Living Will is prepared for) states his/her intention to make a Living Will. Press [Ctrl+F1] for more information.
This required section states the circumstances under which life-sustaining procedures or treatment will be withheld or withdrawn, and includes an optional "coma" provision. Press [Ctrl+F1] for more information.
This is a required section in which the Declarant states whether artificially administered nutrition and hydration (food and fluids) should be withheld or withdrawn. Press [Ctrl+F1] for more information.
This optional section states what effect should be given to the Living Will if the Declarant is pregnant. Press [Ctrl+F1] for more information.
This is an optional section which allows for additional specific instructions and requests. Press [Ctrl+F1] for more information.
This optional section designates a "Proxy" to make health care decisions if the Declarant is unable to do so. Press [Ctrl+F1] for more information.
This recommended provision provides that the inclusion of an invalid request or instruction does not invalidate the other provisions. Press [Ctrl+F1] for more information.
This required section provides the signature line for the Declarant who must sign in the presence of witnesses and/or a Notary Public. Press [Ctrl+F1] for more information.
This required section provides signature lines for the witnesses in accordance with state law requirements. Press [Ctrl+F1] for more information.
This required section provides the acknowledgement paragraph that is completed by the Notary Public (or other person taking the acknowledgement) at the time of signing the document. Press [Ctrl+F1] for more information.
Times New Roman
Living Will
LIW_HI
The Living Will is a document under which a competent adult, prior to becoming unconscious or incompetent, declares his/her intention that withholding or withdrawal of life-sustaining procedures should be withheld or withdrawn under certain circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WHI01
! Declaration Section (1 of 10)
DECLARATION
A. Statement of Declarant
Declaration made this _____ day of _______________, 19___.
I, !, being of sound mind, and understanding that I have the right to request that my life be prolonged to the greatest extent possible, 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:
A Living Will is prepared for a "Declarant". In this required section, the Declarant states his/her intentions regarding life-sustaining procedures or treatment during terminal or life threatening circumstances.
A Living Will is prepared for a "Declarant". Enter the Declarant's name or edit the information as desired. A Living Will directs the Declarant's physician to withdraw or withhold life-sustaining procedures if the Declarant is in a terminal condition with no hope of recovery. Press [Ctrl+F1] for more information.
WHI02
! Life Support Section (2 of 10)
My instructions shall prevail even if they create a conflict with the desires of my relatives, hospital policies, or the principles of those providing my care.
If I should develop a terminal condition
! [optional COMA provision] or a permanent loss of the ability to communicate concerning medical treatment decisions, with no reasonable chance of regaining this ability,
I do not want to have my life prolonged. I would not want to be subjected to surgery or resuscitation. Nor would I then wish to have life-sustaining medicine or procedures. Instead, I request care, including medicine and procedures, for the purpose of providing comfort and pain relief.
This is a required section. This section describes the circumstances under which you, the Declarant, want to have life-sustaining procedures or treatment withheld or withdrawn if you become terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
Enter an X if you want to have life-sustaining procedures or treatment withheld or withdrawn if you become permanently unconscious. Press [Ctrl+F1] for more information.
WHI03
! Nutrition Section (3 of 10)
[This checklist must be included in all Hawaii declarations signed after July 1, 1991. Access Document Information for an explanation regarding Artificial Nutrition/Hydration.]
CHECKLIST - ARTIFICIAL FEEDING AND PROVISION OF FLUIDS
I have also considered whether I want tube feeding to be provided and have selected one of the following provisions by putting a mark in the space provided:
_____ I do NOT want my life prolonged by tube or other artificial feeding or provisions of fluids by a tube if my condition is as stated above.
_____ I DO want my life prolonged by tube or other artificial feeding or provisions of fluids by a tube if my condition is as stated above.
If neither provision is selected or if both are selected, it shall be presumed that tube or other artificial feeding or provisions of fluids by a tube are requested to prolong the Declarant's life.
This is a required section that states whether you wish to receive or not to receive artificial nutrition and hydration (food and fluids) if you are terminally ill or permanently unconscious. Press [Ctrl+F1] for more information.
LAL04
! Optional Pregnancy Section (4 of 10)
If I have been diagnosed as pregnant and that diagnosis is known to my physician, this document shall have no force or effect during the course of my pregnancy.
! [Optional additional sentence] However, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life-sustaining procedures, it is my preference that this document be given effect at that point.
! [Optional additional sentence] If life-sustaining procedures will be physically harmful or unreasonably painful to me in a manner that cannot be alleviated by medication, I request that my desire for personal physical comfort be given consideration in determining whether this document shall be effective if I am pregnant.
Enter an X to include a pregnancy section which states that this Living Will will not be enforced if you are pregnant. Certain exceptions to this statement are presented. Press [Ctrl+F1] for more information.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception permits enforcement of the Living Will if the fetus could not develop to the point of live birth with the continued application of life-sustaining procedures.
Enter an X to provide an exception to the invalidity of the Living Will if you are pregnant. This exception requests that pain or physical harm to you be considered in determining whether life-sustaining procedures or treatment should be withheld or withdrawn.
LAL05
! Optional Other Specific Requests Section (5 of 10)
Other specific requests:
Enter an X to include a paragraph that allows you to state other specific requests or instructions.
Use this space to state any other specific requests or instructions.
WHI06
! Optional Proxy Section (6 of 10)
In the absence of my ability to make health care decisions, I hereby appoint !,
currently residing at
!, ! !,
! , !,
as my Attorney-in-fact/Proxy for the purpose of making decisions relating to my health care in my place.
! If the person I have named above refuses or is unable or unavailable to act on my behalf, or if I revoke that person's authority to act as my Attorney-in-fact/Proxy, I appoint!,
currently residing at
!, ! !,
! , !,
as my Attorney-in-fact/Proxy for the purpose of making decisions relating to my health care in my place.
It is my intention that this appointment shall be honored by my Attorney-in-fact/Proxy, and by my family, relatives, friends, physicians and lawyer as the final expression of my legal right to refuse medical or surgical treatment; and I accept the consequences of such a decision.
Enter an X to include a section that allows you to designate someone as a "Health Care Proxy" to make health care decisions for you if you are unable to do so. Press [Ctrl+F1] for more information.
Enter the Proxy's name or use the P.I. Manager to select and paste a record.
Enter the Proxy's street address or edit the information as desired.
Enter the Proxy's extended street address or edit the information as desired.
Enter the Proxy's city or edit the information as desired.
Enter the Proxy's state/province or edit the information as desired.
Enter the Proxy's zip/postal code or edit the information as desired.
Enter an X to include the country in which the Proxy resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X if you wish to designate an Alternate Proxy if the original Proxy refuses or is unable or unavailable to act on your behalf.
Enter the Alternate Proxy's name or use the P.I. Manager to select and paste a record.
Enter the Alternate Proxy's street address or edit the information as desired.
Enter the Alternate Proxy's extended street address or edit the information as desired.
Enter the Alternate Proxy's city or edit the information as desired.
Enter the Alternate Proxy's state/province or edit the information as desired.
Enter the Alternate Proxy's zip/postal code or edit the information as desired.
Enter an X to include the Alternate Proxy's country, if outside the United States.
LAL06
! Optional Severability Section (7 of 10)
If any provision in this document is held to be invalid, such invalidity shall not affect the other provisions which can be given effect without the invalid provision, and to this end the directions in this document are severable.
It is recommended that this severability provision be included to prevent one invalid provision from invalidating the entire document. However, if you do not want to include it, press the spacebar to deselect the checkbox. Press [Ctrl+F1] for information regarding the reasons for including a severability paragraph.
WHI08
! Declarant Signature Section (8 of 10)
This declaration shall control in all circumstances.
I understand the full import of this declaration and I am emotionally and mentally competent to make this declaration.
________________________________________
Signature
Declarant Name: !
Declarant Address:City: !
State: !
! Country: !
! SSN: !
! Birthdate: !
This required section provides a signature line for the Declarant, and requests additional information regarding the Declarant.
Enter the Declarant's city or edit the information as desired.
Enter the Declarant's state/province or edit the information as desired.
Enter an X to include the country in which the Declarant resides, if outside the United States.
Enter the country or edit the information as desired.
Enter an X to include the Declarant's social security number (SSN). By providing the SSN, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Enter the Declarant's social security number or edit the information as desired.
Enter an X to include the Declarant's date of birth. By providing the date of birth, the health care providers will be assisted in maintaining their Living Will files. Press [Ctrl+F1] for more information.
Using the format MM/DD/YYYY, enter the Declarant's date of birth or edit the information as desired.
WHI09
! Witness Signature Section (9 of 10)
[CAREFULLY REVIEW THE RESTRICTIONS ON WHO MAY BE A WITNESS. IF THE DOCUMENT IS NOT PROPERLY WITNESSED, IT MAY NOT BE ENFORCEABLE.]
B. Statement of Witnesses
I am at least 18 years of age and
-not related to the Declarant by blood, marriage, or adoption;
-not currently the attending physician, or an employee of the attending physician, or an employee of the health 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.
This required section provides signature lines for the witnesses, and requests additional information regarding the witnesses.
Enter the FIRST witness' name or use the P.I. Manager to select and paste a record. The witness information may be left blank and be completed when the document is signed. Review the limits on who may be a witness. If the document is not properly witnessed, it may not be enforceable. Press [Ctrl+F1] for more information.
Enter the witness' street address or edit the information as desired.
Enter the witness' extended street address or edit the information as desired.
Enter the witness' city or edit the information as desired.
Enter the witness' state/province or edit the information as desired.
Enter the witness' zip/postal code or edit the information as desired.
Enter an X to include the witness' country, if outside the United States.
Enter the country or edit the information as desired.
Enter the SECOND witness' name or use the P.I. Manager to select and paste a record. The following information regarding the name and address of the witness may be left blank and be completed when the document is signed.
WHI10
! Acknowledgement Section (10 of 10)
[This required section acknowledges that both the witnesses and the Declarant signed this document.]
Subscribed, sworn to and acknowledged before me by !, the Declarant, and subscribed and sworn to before me by ! and !, witnesses, this _____ day of _______________, 19___.
(SEAL) Signed:
________________________________________
________________________________________
(Official capacity of officer)
This is a required section which acknowledges that both the witnesses and the Declarant signed this document. Press [Ctrl+F1] for more information.
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