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Delaware itness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ -8- __________ Date: _________________________________________ I am not prohibited by § 2503 of Title 16 of the Delaware Code from being a witness. _____________________________________________ (Second W Delaware Code from being a witness. -7- _____________________________________________ (First Witness Signature) Print Name: ___________________________________ Address: ____________________________rective, a patient advocate or ombudsman designated by the Division of Services for Aging and Adults with Physical Disabilities or the Public Guardian. I am not prohibited by § 2503 of Title 16 of theeclarant 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 dicontrolling interest in or is an operator or an employee of a residential long-term health-care institution in which the declarant is a resident; or 6. Is under eighteen years of age. C. That if the d the advance health-care directive, a present or inchoate claim against any portion of the estate of the declarant; 4. Has a direct financial responsibility for the declarant's medical care; 5. Has a arant or codicil thereto then existing nor, at the time of the executing of the advance health care directive, is so entitled by operation of law then existing; 3. Has, at the time of the execution oft is mentally competent. B. That neither of them: 1. Is related to the declarant by blood, marriage or adoption; 2. Is entitled to any portion of the estate of the declarant under any will of the decll.C. §§ 2502 and 2503, in our presence, who in his/her presence, at his/her request, and in the presence of each other, have hereunto subscribed our names as witnesses, and state: A. That the DeclaranAddress: ______________________________________ (12) SIGNATURES OF WITNESSES: Statement Of Witnesses SIGNED AND DECLARED by the above-named declarant as and for his/her written declaration under 16 Derpose and effect of this document. Date: _____________________________________ -6- __________________________________________ (Declarant's Signature) Print Name: ___________________________________ available, a physician who undertakes the responsibility. (10) EFFECT OF COPY: A copy of this form has the same effect as the original. (11) SIGNATURE: Sign and date the form here: I understand the pu individual or the individual's agent or guardian, to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably __________________ (address) (city) (phone) (state) (zip code) _____________________________________________________________________________ Primary Physician shall mean a physician designated by anllowing physician as my primary physician: _____________________________________________________________________________ (name of physician) _______________________________________________________________________________________________________________ OPTIONAL: If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the fo_______________________________ (name of physician) _____________________________________________________________________________ (address) (city) (phone) (state) (zip code) _________________________ [ ] therapy; [ ] research; [ ] medical education. PART 4: PRIMARY PHYSICIAN (OPTIONAL) (9) I designate the following physician as my primary physician: ____________________________________________________________________________________; [ ] the following individual for treatment: __________________________ for the following purposes: [ ] any purpose authorized by law; [ ] transplantation; -5- erson or institutions [ ] the physician in attendance at my death; [ ] the hospital in which I die; [ ] the following named physician, hospital, storage bank or other medical institution: ____________squares and words filled into the blanks below indicate my desires. I give: [ ] my body; [ ] any needed organs or parts; [ ] the following organs or parts _________________________; To the following p.) PART 3: ANATOMICAL GIFTS AT DEATH (OPTIONAL) (8) I am mentally competent and 18 years or more of age. I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate ect that: ______________________________________________________________________________ ______________________________________________________________________________ (Add additional sheets if neededMEDICAL INSTRUCTIONS: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I dirs, even if it hastens my death: ______________________________________________________________________________ ______________________________________________________________________________ (7) OTHER ds. _____ I do not want used _____ I do not want used -4- RELIEF FROM PAIN: Except as I state in the following space, I direct treatment for alleviation of pain or discomfort be provided at all timewant used Hydration through a conduit _______ I want used Choice To Prolong Life ________ I want my life to be prolonged as long as possible within the limits of generally accepted health-care standaration, a persistent vegetative state or irreversible coma) and regarding artificial nutrition and hydration, I make the following specific directions: Artificial nutrition through a conduit _______ I at has lasted at least 4 weeks and with reasonable medical certainty as total and irreversible loss of consciousness and capacity for interaction with the environment. The term includes, without limit____ I do not want used _____ I do not want used ________ (ii) I become permanently unconscious (a medical condition that has been diagnosed in accordance with currently accepted medical standards thand regarding artificial nutrition and hydration, I make the following specific directions: Artificial nutrition through a conduit _______ I want used Hydration through a conduit _______ I want used _y injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and from which, despite the application of life-sustaining procedures, there can be no recovery) choice I have marked below: Choice Not To Prolong Life I do not want my life to be prolonged if: (please check all that apply) ________ (i) I have a terminal condition (an incurable condition caused bnt. (6) END-OF-LIFE DECISIONS: If I am in a qualifying condition, I direct that my health-care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the agent to determine what is best for you in making end-of-life decisions, you need not fill out this part of the form. If you do fill out this part of the form, you may strike any wording you do not wa________________________ -3- __________________________________________________ [ ] I do not nominate anyone to be guardian. PART 2: INSTRUCTIONS FOR HEALTH CARE If you are satisfied to allow your this form in the order designated to act as guardian. [ ] I nominate the following to be guardian in the order designated: __________________________________________________ __________________________values to the extent known to my agent. (5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, (please check one): [ ] I nominate the agent(s) whom I named in e unknown, my agent shall make health-care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal isions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form, and my other wishes to the extent known to my agent. To the extent my wishes ar own health-care decisions and my primary physician and another physician determine I am in a terminal condition or permanently unconscious. (4) AGENT'S OBLIGATION: My agent shall make health-care deco decisions concerning the providing, withholding and withdrawal of lifesustaining procedures my agent's authority becomes effective when my primary physician determines I lack the capacity to make myets if needed.) (3) WHEN AGENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines I lack the capacity to make my own health-care decisions. As txcept as I state here: ______________________________________________________________________________ ______________________________________________________________________________ (Add additional she-care decisions for me, except decisions about life-sustaining procedures and as I state here; and if I am in a qualifying condition, my agent is authorized to make all health-care decisions for me, ecode) (work phone) _____________________________________________________________________________ (2) AGENT'S AUTHORITY: If I am not in a qualifying condition my agent is authorized to make all health____________________ (name of individual you choose as second alternate agent) _____________________________________________________________________________ (address) (home phone) (city) (state) (zip or if neither is willing, able, or reasonably available to make a health-care decision for me, I designate as my second alternate agent: -2- _________________________________________________________ (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) OPTIONAL: If I revoke the authority of my agent and first alternate agent ________________________________________________ (name of individual you choose as first alternate agent) _____________________________________________________________________________ (address) (city)I revoke my agent's authority or if my agent is not willing, able, or reasonably available to make a health-care decision for me, I designate as my first alternate agent: _________________________________________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) OPTIONAL: If my agent to make health-care decisions for me: _____________________________________________________________________________ (name of individual you choose as agent) _________________________________ve the right to revoke this advance health-care directive or replace this form at any time. PART 1: POWER OF ATTORNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the following individual asd to any health-care agents you have named. You should talk to the person you have named as agent to make sure that the person understands your wishes and is willing to take the responsibility. You hals sign as witnesses. Give a copy of the signed and completed form to your physician, to any other health-care providers you may have, to any health-care institution at which you are receiving care an 4 of this form lets you designate a physician to have primary responsibility for your health care. After completing this form, sign and date the form at the end. It is required that 2 other individua write out any additional instructions for other than end of life decisions. -1- Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death. Part keep you alive, including the provision of artificial nutrition and hydration as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you tois form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to cardiopulmonary resuscitation and orders not to resuscitate. (e) Direct the providing, withholding or withdrawal of artificial nutrition and hydration and all other forms of health care. Part 2 of thake all health-care decisions for you, including, but not limited to: (c) The decisions listed in (a) and (b). (d) Consent or refuse consent to life sustaining procedures, such as, but not limited to,n unless it's a life-sustaining procedure or otherwise required by law. (b) Select or discharge health-care providers and health-care institutions; If you have a qualifying condition, your agent may magent's authority, your agent will have the right to: (a) Consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental conditiory or permanent unconsciousness), your agent may make all health-care decisions for you except for decisions providing, withholding or withdrawing of a life sustaining procedure. Unless you limit the ntrolling interest in or be an operator or employee of a residential long-term health-care institution at which you are receiving care. If you do not have a qualifying condition (terminal illness/injuions. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, an agent may not have a coorm. Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health-care decisions for you if you become incapable of making your own decis express your wishes regarding anatomical gifts and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different fgive instructions about your own health care. You also have the right to name someone else to make health-care decisions for you. This form lets you do either or both of these things. It also lets you professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Advance Health Care Directive EXPLANATION You have the right to articular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possible tax consequences arising out of this document should be discussed with a taxly be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you should have an attorney review it to make sure it fits your p to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should onthe following form (see below for form): [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or ase directive. The other sections of this chapter govern the effect of this or any other writing used to create an advance health-care directive. An individual may complete or modify all or any part of represent a suspension of an advance health-care directive while receiving such emergency treatment. 2505. Optional form. The following form may, but need not, be used to create an advance health-cardirective that conflicts with an earlier advance health-care directive revokes the earlier directive to the extent of the conflict. -3- (f) The initiation of emergency treatment shall be presumed to filing of a petition for divorce revokes a previous designation of a spouse as an agent unless otherwise specified in the decree or in a power of attorney for health care. (e) An advance health-care ct of the revocation to the supervising health-care provider and to any health-care institution at which the patient is receiving care. (d) A decree of annulment, divorce, dissolution of marriage or aall be made a part of the medical record. (c) Any person, including, but not limited to, a health care provider, agent or guardian, who is informed of a revocation shall immediately communicate the fa presence of 2 competent persons, 1 of whom is a health care provider. (b) Any revocation that is not in writing shall be memorialized in writing and signed and dated by both witnesses. This record sh. (a) An individual who is mentally competent may revoke all or part of an advance healthcare directive: (1) By a signed writing; or (2) In any manner that communicates an intent to revoke done in theso long as it is probable that the fetus will develop to be viable outside the uterus with the continued application of a life-sustaining procedure. § 2504. Revocation of advance health-care directivedvance health-care directive may include the individual's nomination of a guardian of the person. (j) A life-sustaining procedure may not be withheld or withdrawn from a patient known to be pregnant, e or adoption, an agent may not have a controlling interest in or be an operator or employee of a residential long-term healthcare institution at which the principal is receiving care. (i) A written aors, if applicable, stated in this subsection. (g) A health-care decision made by an agent for a principal is effective without judicial approval. (h) Unless related to the principal by blood, marriagecision shall be made in the best interest of the patient. To the extent the agent knows and is able to determine, the agent's decision is to take into account, including, but not limited to, the factde to family members, friends, health care providers or religious leaders. -2- If the agent is unable to determine what the patient would have done or intended under the circumstances, the agent's dikelihood of death; (4) The treatment's burdens on and benefits to the patient; and (5) Reliable oral or written statements previously made by the patient, including, but not limited to, statements mao, the following factors if applicable: (1) The patient's personal, philosophical, religious and ethical values; (2) The patient's likelihood of regaining decision making capacity; (3) The patient's l the patient would have done or intended under the circumstances. To the extent that the agent knows or is able to determine, the agent's decision is to take into account, including, but not limited tf any, and other wishes to the extent known to the agent. If the patient's instructions or wishes are not known or clearly applicable, the agent's decision shall conform as closely as possible to whatultation with the attending physician or with the person other than a physician designated pursuant to subsection (e) of this section, and in accordance with the principal's individual instructions, iin a notarized document that the individual lacks or has recovered capacity. (f) An agent shall make a health-care decision to treat, withdraw or withhold treatment on behalf of the patient after cons however, a power of attorney for health care may include a provision accommodating an individual's religious or moral beliefs. That provision may designate a person other than a physician to certify has recovered capacity that affects an individual instruction or the authority of an agent must be made by the primary physician or other physician(s) as specified in a written health-care directive; has a qualifying condition. (d) An advance health-care directive ceases to be effective upon a determination that the declarant has recovered capacity. (e) A determination that an individual lacks oried to the providing, withholding or withdrawal of a life-sustaining procedure, the advance health-care directive shall become effective only upon a determination that the declarant lacks capacity and from being a witness. (c) An advance health-care directive shall become effective only upon a determination that the declarant lacks capacity, and when the advance health-care directive is to be applealth care institution at which the declarant is a patient or resident. (2) Each witness to the advance health-care directive shall state in writing that he or she is not prohibited under this section any portion of the estate of the declarant; -1- 4. Has a direct financial responsibility for the declarant's medical care; or 5. Has a controlling interest in or is an operator or an employee of a hpower of attorney for health care, is entitled thereto by operation of law then existing; 3. Has, at the time of the execution of the advance health care directive, a present or inchoate claim against, marriage or adoption; 2. Is entitled to any portion of the estate of the declarant under any will or trust of the declarant or codicil thereto then existing nor, at the time of the executing of the person in the declarant's presence and at the declarant's expressed direction; c. Dated; d. Signed in the presence of 2 or more adult witnesses neither of whom: 1. Is related to the declarant by bloode agent to make any health-care decision the principal could have made while having capacity. (b) (1) An advance health-care directive must be: a. In writing; b. Signed by the declarant or by another : (1) Give an individual instruction. The instruction may be limited to take effect only if a specified condition arises; and/or (2) Execute a power of attorney for health care, which may authorize thare Statutes relating to the Delaware Advance Health Care Directive Form. § 2503. Advance health-care directives. (a) Subject to the limitations of this chapter, an adult who is mentally competent mayalth Care Directive (Power of Attorney for Health Care and Living Will) is based on Title 16 Chapter 25 Section 2503 et. Seq. of the Delaware Statutes. The following are useful excerpts from the Delawh Care Directive (Power of Attorney for Health Care and Living Will) Form; (2) Delaware Advance Health Care Directive (Power of Attorney for Health Care and Living Will) Form. This Delaware Advance HeInformation and Instructions Delaware Advance Health Care Directive (Power of Attorney for Health Care and Living Will) This package contains (1) Information and Instruction for Delaware Advance Healt Delaware