DURABLE POWER OF ATTORNEY FOR HEALTH CARE

(State of Hawaii)

TABLE OF CONTENTS

1. Document Header
2. Definitions
3. Appointment of Agent & Grant of Authority
4. End-of-Life Instructions
5. HIPAA Authorization & Medical Information Access
6. Standards, Duties, and Limitations of Agent
7. Successor Agents
8. Nomination of Guardian or Conservator
9. Revocation & Amendments
10. Default, Remedies & Injunctive Relief
11. Risk Allocation: Indemnification & Liability Limitation
12. Dispute Resolution
13. General Provisions
14. Execution & Attestation Blocks

1. DOCUMENT HEADER

This Durable Power of Attorney for Health Care (this “Instrument”) is made effective as of [EFFECTIVE DATE] (the “Effective Date”) by [PRINCIPAL FULL LEGAL NAME], date of birth [MM/DD/YYYY], residing at [ADDRESS] (the “Principal”).

Recitals
A. Principal desires to ensure that health-care decisions are made in accordance with Principal’s wishes in the event Principal is unable to make or communicate such decisions personally.
B. Pursuant to the Hawaii Uniform Health-Care Decisions Act, Principal is authorized to appoint an agent to make health-care decisions on Principal’s behalf.
C. Consideration is acknowledged by the mutual promises contained herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged.

2. DEFINITIONS

“Act” means the Hawaii Uniform Health-Care Decisions Act, Haw. Rev. Stat. § 327E-1 et seq.
“Advance Directive” means any written statement of Principal’s desires concerning health-care, including this Instrument.
“Agent” means the individual designated in Section 3.1 to act for Principal.
“Alternate Agent” means any individual designated in Section 7 to serve if the primary Agent is unable or unwilling to serve.
“Good Faith” means honesty in fact in the conduct of the transaction concerned.
“Health-Care Decision” has the meaning set forth in the Act and includes consent, refusal, or withdrawal of consent to any care, treatment, service, or procedure.
“HIPAA” means the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations.
“Incapacitated” means lacking capacity to understand the significant benefits, risks, and alternatives to proposed health-care and to make and communicate a health-care decision, as determined under Section 3.4.
“Principal” has the meaning set forth in the Document Header.

3. APPOINTMENT OF AGENT & GRANT OF AUTHORITY

3.1 Appointment. Principal hereby designates [AGENT FULL LEGAL NAME], residing at [ADDRESS], telephone [PHONE], as Principal’s true and lawful health-care agent (“Agent”).

3.2 Scope of Authority. Subject to the limitations in this Instrument and the Act, Agent is authorized to make any and all Health-Care Decisions for Principal that Principal could make if not Incapacitated, including but not limited to:
a. selection and discharge of health-care providers and facilities;
b. approval or refusal of diagnostic tests, surgical procedures, medication, and life-sustaining treatment;
c. direction of pain relief and palliative care;
d. access to, and release of, medical records;
e. anatomical gifts, autopsy, and disposition of remains, subject to Section 4.4.

3.3 Durable Nature. This appointment is durable and shall not be affected by Principal’s subsequent incapacity.

3.4 Determination of Incapacity. Principal shall be deemed Incapacitated upon either:
a. written determination by the primary physician; or
b. determination by a court of competent jurisdiction.

3.5 Effective Period. Agent’s authority commences upon the earlier of (i) Principal’s Incapacity or (ii) written election by Principal. Authority terminates upon revocation pursuant to Section 9.

4. END-OF-LIFE INSTRUCTIONS

4.1 Life-Sustaining Treatment. If Principal suffers from a terminal condition or is permanently unconscious, it is Principal’s desire that:
□ Life-sustaining treatment be withheld or withdrawn.
□ Life-sustaining treatment be provided.

4.2 Artificial Nutrition & Hydration.
□ Withhold/Withdraw artificial nutrition and hydration.
□ Provide artificial nutrition and hydration.

4.3 Palliative Care. Principal requests maximum pain relief even if such relief may hasten death, consistent with Good Faith medical practice.

4.4 Anatomical Gifts. Principal:
□ Authorizes any needed organs or tissues for transplant, therapy, research, or education.
□ Declines to make anatomical gifts.
□ Limits gifts to: [SPECIFY].

5. HIPAA AUTHORIZATION & MEDICAL INFORMATION ACCESS

5.1 Authorization. To the fullest extent permitted by HIPAA, Principal authorizes any covered entity to disclose to Agent all protected health information (“PHI”) relating to Principal.

5.2 Redisclosure. Agent may redisclose PHI as necessary to carry out Agent’s duties, subject to HIPAA.

5.3 Duration & Survival. This authorization is effective immediately and survives Principal’s death to the extent necessary to obtain records related to post-mortem decisions.

6. STANDARDS, DUTIES, AND LIMITATIONS OF AGENT

6.1 Decision-Making Standard. Agent shall act (i) in accordance with Principal’s expressed instructions; or (ii) if no instruction exists, in Agent’s Good Faith judgment of Principal’s best interest, considering Principal’s personal values.

6.2 Consultation. Agent shall consult with treating physicians and, when feasible, with family members and spiritual advisors.

6.3 Conflicts of Interest. Agent shall disclose any actual or potential conflicts and shall not benefit financially from Principal’s death beyond ordinary fiduciary compensation.

6.4 Compensation & Expenses. Agent serves without compensation but is entitled to reimbursement of reasonable out-of-pocket expenses from Principal’s estate.

6.5 Limitations. Agent may not:
a. consent to involuntary commitment;
b. consent to psychosurgery, sterilization, or abortion without express written authority;
c. override any limitation expressly stated in this Instrument.

7. SUCCESSOR AGENTS

7.1 First Alternate Agent: [ALTERNATE AGENT #1 NAME, ADDRESS, PHONE].
7.2 Second Alternate Agent: [ALTERNATE AGENT #2 NAME, ADDRESS, PHONE].
7.3 Each Alternate Agent shall serve successively, not concurrently, in the order listed.

8. NOMINATION OF GUARDIAN OR CONSERVATOR

If a court determines that a guardian or conservator is necessary, Principal nominates the serving Agent as first choice and the Alternate Agents in the order stated in Section 7 as successors.

9. REVOCATION & AMENDMENTS

9.1 Revocation by Principal. This Instrument may be revoked at any time by:
a. a signed writing by Principal;
b. oral statement in the presence of a witness age 18 or older; or
c. any other act evidencing intent to revoke (e.g., destroying the original).

9.2 Automatic Revocation. Appointment of Principal’s spouse as Agent is revoked upon legal separation or divorce unless reaffirmed in writing.

9.3 Amendments. Amendments must be in writing, signed by Principal, and executed with the same formalities as this Instrument.

10. DEFAULT, REMEDIES & INJUNCTIVE RELIEF

10.1 Events of Default. The following constitute defaults:
a. Agent’s failure to act when required;
b. Agent’s breach of fiduciary duty or acting outside scope.

10.2 Remedies. Upon default, any interested person may petition the state probate court for:
a. suspension or removal of Agent;
b. appointment of an Alternate Agent;
c. specific performance or declaratory relief.

10.3 Injunctive Relief. Because Health-Care Decisions are time-sensitive, injunctive relief consistent with the Principal’s health-care directives may be sought without the posting of bond.

11. RISK ALLOCATION: INDEMNIFICATION & LIABILITY LIMITATION

11.1 Indemnification. Principal agrees to indemnify and hold harmless Agent (and any Alternate Agent) from any claim, loss, or expense arising out of lawful acts or omissions taken in Good Faith under this Instrument.

11.2 Liability Limitation. No Agent shall be liable for actions taken in Good Faith and in accordance with the Act, this Instrument, or court order.

12. DISPUTE RESOLUTION

12.1 Governing Law. This Instrument shall be governed by the laws of the State of Hawaii, including the Act (“state_healthcare_law”).

12.2 Forum Selection. Exclusive jurisdiction and venue lie in the state probate court of the circuit in which Principal resides or is located.

12.3 Arbitration & Jury Waiver. Arbitration is not available, and no party waives their right to a jury trial as a matter of contract.

13. GENERAL PROVISIONS

13.1 Severability. If any provision is found invalid, remaining provisions shall remain in full force and effect.

13.2 Integration. This Instrument constitutes the entire advance directive of Principal and supersedes prior inconsistent writings.

13.3 Copies. Photocopies, facsimiles, and electronically signed counterparts shall be as effective as originals.

13.4 Reliance. Any third party may rely on a copy of this Instrument without inquiry into validity or revocation unless actual notice exists.

13.5 Electronic Signatures. Electronic signatures are valid where permitted by law.

14. EXECUTION & ATTESTATION BLOCKS

14.1 SIGNATURE OF PRINCIPAL

I, [PRINCIPAL NAME], declare that I am at least 18 years old, of sound mind, and voluntarily execute this Instrument on the date written below.

Signature: _________________________________
Printed Name: ______________________________
Date: ______________________

14.2 WITNESS ATTESTATION (two witnesses required unless notarized)

Each witness declares under penalty of perjury that (i) the Principal is personally known to the witness, (ii) Principal signed or acknowledged this Instrument in the witness’s presence, (iii) the witness is at least 18 years old, (iv) the witness is not the Agent, Alternate Agent, or related to Principal by blood, marriage, or adoption, (v) the witness is not entitled to any portion of Principal’s estate, and (vi) the witness is not directly financially responsible for Principal’s medical care.

Witness #1
Signature: _________________________________
Printed Name: ______________________________
Address: __________________________________
Date: ______________________

Witness #2
Signature: _________________________________
Printed Name: ______________________________
Address: __________________________________
Date: ______________________

14.3 NOTARY PUBLIC ACKNOWLEDGMENT (optional alternative to two witnesses)

State of Hawaii )
County of ______ ) ss.

On this ___ day of __________, 20___, before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], proved to me through satisfactory evidence of identification to be the person whose name is signed above, and acknowledged execution of the same as Principal’s free and voluntary act.

Notary Public Signature: ______________________________
Name (typed/printed): _________________________________
My commission expires: _______________________________