Fillable Printable Health Care Power of Attorney Form - Delaware

Health Care Power of Attorney Form - Delaware

Advance Health Care Directive

________________________________________________________________

This form was developed by the Committee on Law and the Elderly of the Delaware Bar

Association and approved for use by the Office of the Attorney General of the State of

Delaware.

Advance Health Care Directive of ________________________________________________________ Page 2

GENERAL INSTRUCTIONS

You should read this form carefully before filling it in. You should fill it in completely.

If there are health care decisions you do not want to make, you should strike the wording

of that decision rather than leave it blank. You may not change the qualifications for

witnesses or agents, even if you cross out t he wording . You should write legibly.

After you have filled out the form completely, you should sign the form before a

notary public. Although signing before a notary public is not legally required, it is

advisable. It is advisable because the notary, as well as your witnesses, can testify as to

your competence when you sign the directive, if your competence becomes an issue.

Notaries, who are registered with the State, are often easier to locate later than

witnesses.

You should retain your original Advance Health care Directive, and give copies to

your doctor, agent, spouse, f amily member s, and close friends, if you desire. You should

explain to each person who receives a copy of your health care directive what choices

you m ade on t he f orm , and why. T his will help if, while you lack compet ence, t here ar ises

a need to make a health care decision that is not explicitly set forth on your advance

health car e dir ective f o r m .

This form does not contain all of the types of health care decisions you are legally

entitled to make. For example, the form does not give you the opportunity to nominate a

guardian, in the event you become incompetent and need one. Also, the form does not

give you the opportunity to designate a primary care physician, or another person, to

certify that you lack the capacity to make your own decisions on health care. Finally, the

form does not include a provision that accommodates a person’s religious or moral

beliefs. If you would like to exercise these options, you should talk to an attorney. If

anything on the form conflicts with your relig ious beliefs, you should contact your cler gy.

PART I. INSTRUCTIONS FOR HEALTH CARE DECISIONS

If you are an adult who is mentally competent, you have the right to accept or refuse

medical or surgical treatment, if such refusal is not contrary to existing public health laws. You

may give advance instructions for medical or surgical treatment that you want or do not want.

These instructions will become effective if you lose the capacity to accept or refuse medical or

surgical treatment. You may limit your instructions to take effect only if you are in a specified

medical condition. If you give an instruction that you do not want your life prolonged, that

instruction will only take effect if you are in a “qualifying condition.” A “qualifying condition” is

either a t er m inal condit ion or per m anent unconsciousness.

If you want t o give instruct ions to accept or r efuse medical or sur gical t r eatment, you

should fill in t he spaces on t he following page. You m ay cross out any wording you do not

want.

Advance Health Care Directive of ________________________________________________________ Page 3

A. END OF LIFE INSTRUCTIONS

1. Choice To Pr olong Life

_____I want my life t o be pr olonged as long as possible within the lim its of generally

accepted healt h car e st andar ds.

2. Choice Not To Prolong Life

I do not want my life t o be prolonged if (please check all t hat apply)

____ (i) I have a ter minal condit ion (an incurable condit ion from which there is no

reasonable m edical expectat ion of r e covery and wh ich will cause my death, regar dless

of t he use of life- sust aining t reat m ent ) . I n t his case, I give the specific dir ections

indicated:

I want used I do not want used

Art ificial nut r it ion t hr ough a conduit _______ _______

Hydration through a conduit _______ _______

Cardiopulm onar y resuscit at ion _______ _______

Mechanical respir at ion _______ _______

Ot her ( explain) ________________ _______ _______

____________________________

_____ (ii) I become permanently unconscious (a medical condition that has existed at

least four (4) weeks and has been diagnosed in accordance with currently accepted

medical standards and with reasonable medical certainty as total and irr ever sible loss of

consciousness and capacity for interaction with the environment. The term includes,

without limitation, a persistent vegetative state or irreversible coma) and regarding the

following, I give the specific direct ions indicat ed:

I want used I do not want used

Art ificial nut r it ion t hr ough a conduit _______ _______

Hydration through a conduit _______ _______

Cardiopulm onar y resuscit at ion _______ _______

Mechanical respir at ion _______ _______

Ot her ( explain) ________________ _______ _______

____________________________

B. RELIEF FROM PAIN: W hether I choose A.1 or A.2, or neither, I direct that in all cases I

be given all medically appropriate car e necessar y to m ake me com fort able and alleviate pain.

C. OTHER MEDICAL INSTRUCTION: If you wish to add to the instructions you have given

above, you may do so here.

_________________________________________________________________________________

(use additional sheets if necessary)

Advance Health Care Directive of ________________________________________________________ Page 4

PART II: POWER OF ATTORNEY FOR HEALTH CARE

Your ag ent m ay make any health car e decision that you could have made while you had

the capacity to make health care decisions. You may appoint an alternate agent to make

health care decisions for you if your first agent is not willing, able and reasonably available to

make decisions for you. Unless the persons you name as agent and alternate agent are

related to you by blood, neither may own, operate or be employed by any residential long-term

care inst it ution where you are receiving car e.

If you wish to appoint an agent to make health care decisions for you under these

circumstances and conditions, you must fill out the section below. You may cross out any

wording you do not want.

A. DESIGNATION OF AGENT: I desig nat e _____________________________________

as my agent to make health care decisions for me. If he/she is not living, willing or able, or

reasonably available, to make health care decisions for me, then I designate ________

________________________ as my agent t o make healt h car e decisions for m e.

___________________________________________________________________________

(name of i ndi vi dual you choos e as agent )

___________________________________________________________________________

(address) (city) (state) (zip code)

___________________________________________________________________________

(home phone) (work phone)

___________________________________________________________________________

(name of i ndi vi dual you choos e as alternat e agent)

___________________________________________________________________________

(address) (city) (state) (zip code)

___________________________________________________________________________

(home phone) (work phone)

B. AGENT’S AUTHORITY: I grant to my agent full authority to make decisions for me

regarding my health care; provided that, in exercising this authority, my agent shall follow my

desires as stated in this document or otherwise known to my agent. Accordingly, my agent is

author ized as follows:

1. To consent to, refuse, or withdraw consent to any and all types of medical care,

treatment, surgical procedures, diagnostic procedures, medication, and the use of mechanical

or ot her pr ocedur es that affect any bodily function;

2. To have access to medical records and information to the same extent that I am

entit led t o, including t he r ight t o disclose the cont ent s t o other s;

3. To authorize my admission to or discharge from any hospital, nursing home,

resident ial car e , assisted living or similar facilit y or service;

4. To contract for any health care related service or facility on my behalf, without my

agent incur r ing per sonal financial liability f or such cont r a ct s;

5. To hire and fire medical, social service, and other support personnel responsible for

my care; and

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6. To authorize, or refuse to authorize, any medication or procedure intended to relieve

pain, even though such use may lead to physical damage, addiction, or hasten the moment of

(but not intent ionally cause) m y death.

C. WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes

effective when my attending physician determines I lack the capacity to make my own health

care decisions.

D. AGENT’S OBLIGATION: My agent shall m ake health car e decisions for me in accor dance

with this power of attorney for health care, any instructions I give in Part I of this form, and my

other wishes to the extent known to my agent. To the extent my wishes are unknown, health

care decisions by my agent shall conform as closely as possible to what I would have done or

intended under the circumstances. If my agent is unable to determine what I would have done

or intended under the circumstances, my agent will make health care decisions for me in

accordance with what my agent determines to be my best interest. In determining my best

inter est , my ag ent shall consider my personal values to t he extent known to my agent.

PART III. ANATOMICAL GIFT DECLARATION (Optional)

I hereby make the f ollowing anatomical gift(s) to take ef fect upon my death. The marks

in the appr opr iat e squares and words f illed into t he blanks below indicate my desires:

I give [ ] m y body; [ ] any needed org ans or part s;

[ ] t he following organs or part s _________________________________________

to [ ] the physician in attendance at m y death; [ ] the hospit al in which I die;

[ ] t he following nam ed physician, hospit al, st or age bank or ot her m edical instit ut ion

_____________________________________________________________

for t he following pur pose( s) :

[ ] any purpose aut hor ized by law; [ ] t ransplant at ion;

[ ] therapy; [ ] research;

[ ] m edical education.

EFFECT OF COPY: A copy of t his form has t he sam e effect as the or iginal.

I under st and t he pur pose and effect of this docum ent .

_________________________ _________________________________________

(date) (si gn your name)

_________________________________________

(print your name)

______________________________________________________

(address)

_________________________________________

(city) (state) (zip c ode )

STATEMENT OF WITNESSES

SIGNED AND DECLARED by the above-named declarant as and for his/her written

declaration under 16 Del.C. §§ 2502, 2503, in our presence, who in his/her presence, at his/her

Advance Health Care Directive of ________________________________________________________ Page 6

req uest, and in the presence of each ot her, have hereunto subscribed our names as witnesses,

and stat e:

A. The Declarant is m entally competent.

B. That neit her of us is prohibit ed by §2503 of Title 16 of the Delaware Code fr om

being a witness. Neit her of us:

1. Is related t o t he declarant by blood, m ar r iage or adoption;

2. Is ent it led to any portion of the est at e of the declar ant under any will of

the declar ant or codicil ther et o t hen existing nor , at the t ime of the

executing of the advance health car e dir ective, is so entitled by operation

of law then existing;

3. Has, at t he time of the execution of the advance health care dir ective, a

present or inchoat e claim ag ainst any portion of the est at e of the

declarant;

4. Has a direct financial responsibilit y for t he declarant ' s m edical car e;

5. Has a controlling int erest in or is an oper at or or an employee of a

health car e inst itut ion in which the declarant is a patient or r e sident ; or

6. Is under eight een years of age.

C. That if the declarant is a resident of a sanitarium, rest home, nursing home,

boarding home or related institution, one of the witnesses, __________________

___________________, is at the time of the execution of the advance health care

directive, a patient advocate or ombudsman designated by the Division of Services

for Aging and Adults with Physical Disabilities or the Public G uar dian.

Witness Witness

__________________________________ __________________________________

(print name) (print name)

__________________________________ __________________________________

(address) (address)

__________________________________ __________________________________

(ci ty, st ate, zi p code) (ci ty, st ate, zi p code)

__________________________________ __________________________________

(si gnat ure of witnes s) (date) (si gnat ure of witnes s) (date)

(Optional)

Sworn and subscr ibed t o m e this _____ day of _________________________.

My term expires: _______________________ __________________________________

(Notary)