Declaration as provided by hawaii revised statutes chapter 327d.
A. Statement of Declarant
Declaration made this __________________ day of
_____________, 19_______. I, State the name of the declarant 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withheld or withdrawn, and that I be permitted to die naturally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
State the name of the declarant
STATE OF Enter the state where executed
COUNTY OF Enter the county where executed
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.
Subscribed, sworn to and acknowledged before me by
State the name of the declarant, the declarant, and subscribed and sworn to before me by
___________________ and ___________________, witnesses, this
______________ day of ________________________, 19_______.
Official Capacity: _________________