Durable Power of Attorney for Health Care - Hawaii

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C. OTHER SPECIAL CONDITIONS:
(Be as specific as possible; SEE SUGGESTIONS.):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(Cross off any remaining blank lines.)
IF I AM PREGNANT
D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and
health care attorney in fact(s) to use all lifesaving procedures for myself with none of the above
special conditions applying if there is a chance that prolonging my life might allow my child to
be born alive. I also direct that lifesaving procedures be used even if I am legally determined to
be brain dead if there is a chance that doing so might allow my child to be born alive. Except as I
specify by writing my signature in the box below, no one is authorized to consent to any
procedure for me that would result in the death of my unborn child.
If I am pregnant, and I am not in the final stage of a terminal condition as defined above,
medical procedures required to prevent my death are authorized even if they may result in the
death of my unborn child provided every possible effort is made to preserve both my life and the
life of my unborn child.
____________________________________
Signature of Declarant
EFFECT OF COPY
A copy of this form has the same effect as the original.
Signed this ____________________day of ___________________________, 20_______.
(Signature)____________________________________________________________________
(Print Name)___________________________________________________________________
WITNESSES
This power of attorney will not be valid for making health-care decisions unless it is either (a)
signed by two qualified adult witnesses who are personally known to you and who are present
when you sign or acknowledge your signature; or (b) acknowledged before a notary public in the
state.
FIRST ALTERNATIVE
I declare under penalty of false swearing pursuant to §710-102, Hawaii Revised Statutes, that the
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