Hawaii Advance Directive for Nursing Home and Hospice Admission

When a parent or spouse is admitted to a nursing home or enrolled in hospice in Hawaii, the intake coordinator asks for an advance directive. If the patient does not have one, the facility will offer to help create one — but the witness rules inside a care facility are so restrictive that getting it signed correctly becomes significantly harder.

Understanding what the facility needs, what documents to bring, and how the advance directive connects to the POLST system prevents the administrative delays that hold up admission and care planning.

Why Facilities Require Advance Directives

Federal law (the Patient Self-Determination Act) requires all Medicare- and Medicaid-certified facilities to ask about advance directives at admission. Hawaii state law under HRS Chapter 327E reinforces this: facilities must document whether the patient has a directive and, if so, include it in the medical record.

Facilities are not legally allowed to condition admission on having a directive. But in practice, not having one creates friction. The care team cannot make decisions about life-sustaining treatment without either documented patient wishes or a designated healthcare agent. Every decision defaults to the consensus surrogate process — slow, uncertain, and vulnerable to family disagreement.

For hospice enrollment specifically, the POLST form is typically expected alongside the advance directive. Hospice care presumes a comfort-focused treatment approach, and the POLST translates that presumption into enforceable medical orders that EMS and hospital staff will follow.

The Witness Problem Inside Facilities

If your parent needs to sign an advance directive during or after admission, the witness restrictions under HRS Section 327E-3 create a real obstacle:

• No employee of the facility can serve as a witness
• No healthcare provider involved in the patient's care can serve as a witness
• The patient's designated healthcare agent cannot serve as a witness
• At least one witness must be unrelated and have no estate claim

Inside a nursing home, the staff are the most available people. They are also the most disqualified. A CNA who helps your parent with daily care, a dietary aide who brings meals, the receptionist at the front desk — all disqualified if they are employed by the facility.

Practical Solutions

Bring witnesses from outside: If you know the directive will be signed during admission, bring two qualified witnesses with you. A friend, a colleague, a neighbor — anyone not employed by the facility and not your parent's healthcare agent.

Use a notary: Notarization under HRS Chapter 327E eliminates the witness requirement entirely. Many facilities can arrange for a mobile notary to come to the patient's room. The cost ($25 to $75 for a mobile visit) is negligible compared to the complications of invalid witnesses.

Coordinate with the social worker: Facility social workers deal with advance directives routinely. They know which witness mistakes to avoid and can help arrange alternatives. They cannot serve as witnesses themselves if they are facility employees, but they can facilitate the process.

What Documents to Bring to Admission

Arrive at intake with:

1. Advance Health-Care Directive — signed, witnessed or notarized, with healthcare agent designated
2. POLST form — if the patient has one, signed by the patient and their physician/APRN/PA
3. Advance Mental Health Care Directive — if applicable, especially for dementia patients (separate execution requirements under HRS Chapter 327G)
4. Healthcare agent contact information — the facility needs to reach your agent directly, not route through other family members

If the patient does not yet have a POLST, the facility's medical director or attending physician can initiate the POLST conversation after admission. This is standard for nursing home and hospice patients.

Nursing Home vs. Hospice: Different Care Frameworks

A nursing home advance directive and a hospice advance directive serve the same legal function — they document the patient's wishes and designate a decision-maker. But the clinical context differs.

Nursing home: The patient may live in the facility for years. The advance directive covers a wide range of scenarios — from routine infections to falls to cardiac events. Treatment instructions should address both comfort-focused and curative approaches because the patient's condition may improve, stabilize, or decline over time.

Hospice: The patient has a terminal diagnosis with a life expectancy of six months or less. The advance directive typically aligns with comfort care only — no CPR, no intubation, no transfer to the ICU for aggressive treatment. The POLST form is critical here because it tells EMS to provide comfort measures rather than full resuscitation if called to the scene.

A patient can revoke hospice enrollment at any time and return to curative treatment. If this happens, the advance directive remains in effect but the POLST may need to be updated to reflect the change in treatment goals.

The Facility Cannot Override Your Directive

Hawaii law is clear: a valid advance directive binds the facility. The nursing home or hospice program cannot override the patient's documented wishes or the healthcare agent's decisions — with one exception.

If a facility has a policy against carrying out a specific directive (for example, a religiously affiliated nursing home that will not honor a directive to withdraw artificial nutrition), HRS Section 327E-7 requires the facility to make reasonable efforts to transfer the patient to a facility that will comply. The facility cannot simply ignore the directive and impose its own treatment approach.

This transfer obligation is important for families choosing between facilities on neighbor islands where options are limited. Ask about the facility's policies on life-sustaining treatment during your tour — before admission, not after.

Getting It Done Before Admission

The ideal time to complete an advance directive is before the nursing home or hospice conversation happens. Once admission logistics start, everything moves fast — medical assessments, insurance authorizations, room assignments — and the advance directive gets pushed to "we'll handle it later."

The Hawaii Advance Directive & Living Will Kit is designed to be completed at home before admission, with a POLST coordination reference that ensures your directive and your physician's orders say the same thing when the facility asks for both.

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