Hawaii Our Care Our Choice Act: What Families Need to Know

Hawaii's Our Care, Our Choice Act (OCOCA) — the state's medical aid-in-dying law — imposes some of the most structured procedural requirements in the United States. For terminally ill patients and their families on the islands, understanding what the law requires, how the process works, and what obligations fall on surviving family members is essential before a crisis makes the questions urgent.

Who Qualifies Under the OCOCA

To be eligible for a prescription for life-ending medication under the Our Care, Our Choice Act, a patient must meet all of the following criteria:

• Adult resident of Hawaii. The patient must be 18 years of age or older and a resident of the state.
• Terminal diagnosis. The patient must have a terminal disease with a prognosis of six months or less to live, as independently certified by at least two qualified healthcare providers.
• Decision-making capacity. The patient must be able to make and communicate a voluntary, informed decision about the request.
• Voluntary request. The request must be entirely self-initiated and free from coercion, duress, or undue influence from family members, healthcare providers, or others.

Patients who do not have decision-making capacity at the time of the request do not qualify, regardless of any prior advance directive or designation of healthcare surrogate. The OCOCA applies only to voluntary, contemporaneous decisions by a competent adult.

The Three-Provider Process

Hawaii requires independent evaluation by three separate healthcare professionals. This is more demanding than most other medical aid-in-dying states:

1. Attending Provider. The patient's primary treating physician or advanced practice registered nurse (APRN). This provider receives the formal requests, prescribes the medication, and must verify the terminal diagnosis and residency. The 2023 amendments to the OCOCA expanded the APRN role to include both Attending and Consulting Provider functions, recognizing that many neighbor island patients cannot access physicians in specialized care settings.

2. Consulting Provider. A second, independent physician or APRN who separately confirms the terminal diagnosis and evaluates whether the patient possesses decision-making capacity. The Consulting Provider must not have a financial relationship with the Attending Provider that could create a conflict of interest.

3. Counseling (Mental Health) Provider. A licensed mental health professional — a psychiatrist, psychologist, licensed clinical social worker, or licensed marriage and family therapist (LMFT). The 2023 amendments added LMFTs as authorized Counseling Providers. This professional conducts a comprehensive evaluation to confirm the patient is not suffering from undertreated depression or another psychiatric condition that impairs their judgment. If the Counseling Provider determines the patient's capacity is impaired, the prescription cannot proceed until the underlying condition is treated.

All three providers must document their findings in the patient's medical record. If any of the three providers declines to participate on conscientious grounds, the patient has the right to be referred to a willing provider.

The Oral and Written Request Requirements

The OCOCA mandates a specific sequence of requests before the prescription can be issued:

Two oral requests. The patient must make two separate verbal requests to their Attending Provider, with a minimum of five days between them. The original OCOCA required a 20-day waiting period; the 2023 amendments reduced this to five days to prevent patients with rapidly deteriorating conditions from dying before the process could be completed.

One written request. The patient must complete and sign the Patient's Written Request for Medication and Declaration of Witnesses form. This document must be signed in the presence of two independent witnesses who attest that:

• The patient signed voluntarily and is of sound mind
• Neither witness is a beneficiary of the patient's estate
• Neither witness is the patient's healthcare provider or an employee of the facility where the patient receives care

The written request is submitted to the Attending Provider and becomes part of the permanent medical record.

Neighbor Island Access Challenges

Physician shortages on Maui, Hawaii Island, and Kauai have historically made it difficult for patients on neighbor islands to complete the three-provider process. The 2023 amendments that authorized APRNs as Attending and Consulting Providers and LMFTs as Counseling Providers directly addressed this gap. Telehealth consultations are also permissible under amended Hawaii healthcare regulations, which allows patients in remote areas to complete at least the consulting evaluation remotely when in-person visits are logistically impossible.

Families supporting a terminally ill patient on a neighbor island should proactively ask the Attending Provider which Consulting and Counseling Providers they work with and whether telehealth options are available.

What Happens to Unused Medication

This is the obligation that falls squarely on surviving family members after the patient dies — whether or not the medication was used.

If the patient dies of the underlying terminal illness before self-administering the medication, or if unused medication remains after death, the law requires prompt disposal. Surviving family members or the designated individual must deliver the unused medication to a qualified facility that lawfully accepts controlled substances for disposal, or to a statewide medication drop box.

Storing the medication indefinitely is not legal. Disposing of it through ordinary household trash or flushing it is not the compliant method under Hawaii law. The DEA-authorized medication take-back programs and law enforcement-run drop boxes are the correct channels. If you are uncertain which locations near you accept controlled substances, contact the dispensing pharmacy or the Hawaii Department of Health.

This obligation applies regardless of whether the family knew the patient obtained the medication or was involved in the process.

How the OCOCA Intersects With Estate Administration

When a patient dies under the OCOCA, the death certificate lists the underlying terminal disease — not the medication — as the cause of death. This matters for life insurance claims: Hawaii law explicitly states that death under the OCOCA does not constitute suicide for purposes of life insurance policies. Insurers cannot deny a claim on suicide exclusion grounds when the death occurred under a lawful OCOCA prescription.

For estate administration purposes, the death is treated identically to any other natural death. Certified death certificates are issued by the Hawaii Department of Health, and all standard survivor benefits — ERS pensions, EUTF health coverage, workers' compensation if applicable, Social Security survivor benefits — apply normally.

If navigating survivor benefits and estate administration after a death under the OCOCA, the Hawaii Survivor Benefits Navigator covers the full post-death administrative process: which agencies to contact, in what order, with what documentation, and what county-specific deadlines apply. The OCOCA's procedural complexity ends when the patient dies; the administrative process the family faces afterward follows the same framework as any Hawaii death.

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