Reports the outcome and circumstances of death of a patient who received aid-in-dying medication.
- Completed by
- Attending provider
- Issued by
- Hawaii State Department of Health, Office of Planning, Policy and Program Development
- Format
- Language
- English
Hawaii POLST Form (Kokua Mau)
Seriously ill patients in Hawaii can carry portable treatment orders on this form, approved by the Department of Health in May 2023 and maintained by Kokua Mau. A Hawaii-licensed physician, APRN or PA who has examined the patient documents CPR status, full, selective or comfort-focused treatment, and artificially administered nutrition, with a summary of the medical condition. The patient or legally authorized representative also signs.
Who completes it
A Hawaii-licensed physician, APRN or PA completes Sections A through C and signs Section D in person; the patient or legally authorized representative signs Section D, and a surrogate selected by consensus also signs Section E.
Submitting and payment
- How to submit it
- Nothing is filed; send the two-page form with the person whenever they are transferred or discharged.
Good to know
- Signatures cannot be applied electronically, and verbal orders by providers are not acceptable on the Hawaii form.
- Lime green paper is strongly recommended so EMS can find it quickly, but white copies are legal; copies must include both sides.
- The pre-May 2023 version remains valid and does not expire; the most recently completed valid POLST supersedes earlier ones.
- A surrogate selected by consensus may withhold artificial nutrition only if the primary physician and a second independent physician certify it under HRS 327E-5.
Get the official form
Download the current version from the source each time; forms change without notice.
Hawaii POLST Form (Provider Orders for Life-Sustaining Treatment)
How this list is checked
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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Frequently asked questions
Can a Hawaii POLST be signed electronically?
No. The fillable PDF can be typed on screen, but the signature fields cannot be completed electronically because the POLST currently must be signed in person. Fill out the PDF, print it two-sided, and sign it. Only one choice may be ticked per section.
Is the Hawaii POLST available in other languages?
Yes. Kokua Mau has translated the POLST form and its consumer guide into 13 languages and offers a multilingual POLST form on its professional page. The Department of Health approved the current English form in May 2023, and the earlier version remains valid.