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Delaware _ Date: _________________________________________ -5- aware Code from being a witness. _____________________________________________ (Second Witness Signature) Print Name: ___________________________________ Address: _____________________________________e) Print Name: ___________________________________ Address: ______________________________________ Date: _________________________________________ I am not prohibited by § 2503 of Title 16 of the DelPhysical Disabilities or the Public Guardian. I am not prohibited by § 2503 of Title 16 of the Delaware Code from being a witness. _____________________________________________ (First Witness Signatur 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 n in which the declarant is a resident; or 6. Is under eighteen years of age. C. That if the declarant is a resident of a sanitarium, rest home, nursing home, boarding home or related institution, oneeclarant; 4. Has a direct financial responsibility for the declarant's medical care; 5. Has a controlling interest in or is an operator or an employee of a residential long-term health-care institutiois so entitled by operation of law then existing; -4- 3. Has, at the time of the execution of the advance health-care directive, a present or inchoate claim against any portion of the estate of the d; 2. Is entitled to any portion of the estate of the declarant under any will of the declarant or codicil thereto then existing nor, at the time of the executing of the advance health care directive, h other, have hereunto subscribed our names as witnesses, and state: A. That the Declarant is mentally competent. B. That neither of them: 1. Is related to the declarant by blood, marriage or adoption DECLARED by the above-named declarant as and for his/her written declaration under 16 Del.C. §§ 2502 and 2503, in our presence, who in his/her presence, at his/her request, and in the presence of eac_________________ (Declarant's Signature) Print Name: ___________________________________ Address: ______________________________________ (7) SIGNATURES OF WITNESSES: Statement Of Witnesses SIGNED ANDthe same effect as the original. (6) SIGNATURE: Sign and date the form here: I understand the purpose and effect of this document. Date: _____________________________________ _________________________ health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility. (5) EFFECT OF COPY: A copy of this form has _______________________________________ Primary Physician shall mean a physician designated by an individual or the individual's agent or guardian, to have primary responsibility for the individual's__________________ (name of physician) _____________________________________________________________________________ (address) (city) (phone) (state) (zip code) ______________________________________not willing, able or reasonably available to act as my primary physician, I designate the following physician as my primary physician: -3- ________________________________________________________________________________ (address) (city) (phone) (state) (zip code) _____________________________________________________________________________ OPTIONAL: If the physician I have designated above is following physician as my primary physician: _____________________________________________________________________________ (name of physician) ________________________________________________________________ for the following purposes: [ [ [ [ [ ] any purpose authorized by law; ] transplantation; ] therapy; ] research; ] medical education. PART 3: PRIMARY PHYSICIAN (OPTIONAL) (4) I designate the] the following named physician, hospital, storage bank or other medical institution: __________________________________________________; [ ] the following individual for treatment: __________________d organs or parts; [ ] the following organs or parts _________________________; To the following person or institutions [ ] the physician in attendance at my death; [ ] the hospital in which I die; [ 2- I hereby make this anatomical gift to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires. I give: [ ] my body; [ ] any neede__________ (Add additional sheets if needed.) _____ I do not want used _____ I do not want used PART 2 ANATOMICAL GIFTS AT DEATH (OPTIONAL) (3) I am mentally competent and 18 years or more of age. -ave given above, you may do so here.) I direct that: ______________________________________________________________________________ ____________________________________________________________________________________________________ (2) OTHER MEDICAL 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 h pain or discomfort be provided at all times, even if it hastens my death: ______________________________________________________________________________ ______________________________________________ife to be prolonged as long as possible within the limits of generally accepted health-care standards. RELIEF FROM PAIN: Except as I state in the following space, I direct treatment for alleviation ofration, I make the following specific directions: Artificial nutrition through a conduit _______ I want used Hydration through a conduit _______ I want used Choice To Prolong Life ________ I want my lf consciousness and capacity for interaction with the environment. The term includes, without limitation, a persistent vegetative state or irreversible coma) and regarding artificial nutrition and hydedical condition that has been diagnosed in accordance with currently accepted medical standards that has lasted at least 4 weeks and with reasonable medical certainty as total and irreversible loss ol nutrition through a conduit _______ I want used Hydration through a conduit _______ I want used _____ I do not want used _____ I do not want used ________ (ii) I become permanently unconscious (a mfrom which, despite the application of life-sustaining procedures, there can be no recovery) and regarding artificial nutrition and hydration, -1- I make the following specific directions: Artificiaeck all that apply) ________ (i) I have a terminal condition (an incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and d others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below: Choice Not To Prolong Life I do not want my life to be prolonged if: (please chce health-care directive or replace this form at any time. PART 1: INSTRUCTIONS FOR HEALTH CARE (1) END-OF-LIFE DECISIONS: If I am in a qualifying condition, I direct that my health-care providers ano any other health-care providers you may have, to any health-care institution at which you are receiving care and to any health-care agents you may have named. You have the right to revoke this advanhealth care. After completing this form, sign and date the form at the end. It is required that 2 other individuals sign as witnesses. Give a copy of the signed and completed form to your physician, t 2 of this form lets you express an intention to donate your bodily organs and tissues following your death. Part 3 of this form lets you designate a physician to have primary responsibility for your well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional instructions for other than end of life decisions. Part Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration asyou use this form, you may complete or modify all or any part of it. You are free to use a different form. Part 1 of this form lets you give specific instructions about any aspect of your health care. own health care. This form lets you to give instructions about your own health care. It also lets you express your wishes regarding anatomical gifts and the designation of your primary physician. If nal. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com -4- Living Will Explanation You have the right to give instructions about yoursituation. 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 tax professioarting 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 particular 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 only be a stving such emergency treatment. [_] 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 as to their revokes the earlier directive to the extent of the conflict. -3- (f) The initiation of emergency treatment shall be presumed to represent a suspension of an advance health-care directive while receipouse as an agent unless otherwise specified in the decree or in a power of attorney for health care. (e) An advance health-care directive that conflicts with an earlier advance health-care directive health-care institution at which the patient is receiving care. (d) A decree of annulment, divorce, dissolution of marriage or a filing of a petition for divorce revokes a previous designation of a st not limited to, a health care provider, agent or guardian, who is informed of a revocation shall immediately communicate the fact of the revocation to the supervising health-care provider and to any(b) Any revocation that is not in writing shall be memorialized in writing and signed and dated by both witnesses. This record shall be made a part of the medical record. (c) Any person, including, bu an advance healthcare directive: (1) By a signed writing; or (2) In any manner that communicates an intent to revoke done in the presence of 2 competent persons, 1 of whom is a health care provider. ide the uterus with the continued application of a life-sustaining procedure. § 2504. Revocation of advance health-care directive. (a) An individual who is mentally competent may revoke all or part of a guardian of the person. (j) A life-sustaining procedure may not be withheld or withdrawn from a patient known to be pregnant, so long as it is probable that the fetus will develop to be viable outs operator or employee of a residential long-term healthcare institution at which the principal is receiving care. (i) A written advance health-care directive may include the individual's nomination ofon made by an agent for a principal is effective without judicial approval. (h) Unless related to the principal by blood, marriage or adoption, an agent may not have a controlling interest in or be ant the agent knows and is able to determine, the agent's decision is to take into account, including, but not limited to, the factors, if applicable, stated in this subsection. (g) A health-care decisirs. -2- If the agent is unable to determine what the patient would have done or intended under the circumstances, the agent's decision shall be made in the best interest of the patient. To the extenpatient; and (5) Reliable oral or written statements previously made by the patient, including, but not limited to, statements made to family members, friends, health care providers or religious leadelosophical, religious and ethical values; (2) The patient's likelihood of regaining decision making capacity; (3) The patient's likelihood of death; (4) The treatment's burdens on and benefits to the e extent that the agent knows or is able to determine, the agent's decision is to take into account, including, but not limited to, the following factors if applicable: (1) The patient's personal, phit's instructions or wishes are not known or clearly applicable, the agent's decision shall conform as closely as possible to what the patient would have done or intended under the circumstances. To thhysician designated pursuant to subsection (e) of this section, and in accordance with the principal's individual instructions, if any, and other wishes to the extent known to the agent. If the patiencity. (f) An agent shall make a health-care decision to treat, withdraw or withhold treatment on behalf of the patient after consultation with the attending physician or with the person other than a pccommodating an individual's religious or moral beliefs. That provision may designate a person other than a physician to certify in a notarized document that the individual lacks or has recovered capauthority of an agent must be made by the primary physician or other physician(s) as specified in a written health-care directive; however, a power of attorney for health care may include a provision as to be effective upon a determination that the declarant has recovered capacity. (e) A determination that an individual lacks or has recovered capacity that affects an individual instruction or the aocedure, the advance health-care directive shall become effective only upon a determination that the declarant lacks capacity and has a qualifying condition. (d) An advance health-care directive ceasee effective only upon a determination that the declarant lacks capacity, and when the advance health-care directive is to be applied to the providing, withholding or withdrawal of a life-sustaining pr (2) Each witness to the advance health-care directive shall state in writing that he or she is not prohibited under this section from being a witness. (c) An advance health-care directive shall becomesponsibility for the declarant's medical care; or -1- 5. Has a controlling interest in or is an operator or an employee of a health care institution at which the declarant is a patient or resident.aw then existing; 3. Has, at the time of the execution of the advance health care directive, a present or inchoate claim against any portion of the estate of the declarant; 4. Has a direct financial rhe declarant under any will or trust of the declarant or codicil thereto then existing nor, at the time of the executing of the power of attorney for health care, is entitled thereto by operation of lction; c. Dated; d. Signed in the presence of 2 or more adult witnesses neither of whom: 1. Is related to the declarant by blood, marriage or adoption; 2. Is entitled to any portion of the estate of thile having capacity. (b) (1) An advance health-care directive must be: a. In writing; b. Signed by the declarant or by another person in the declarant's presence and at the declarant's expressed diretake effect only if a specified condition arises; and/or (2) Execute a power of attorney for health care, which may authorize the agent to make any health-care decision the principal could have made w. § 2503. Advance health-care directives. (a) Subject to the limitations of this chapter, an adult who is mentally competent may: (1) Give an individual instruction. The instruction may be limited to in part on Title 16 Chapter 25 Section 2503 et. Seq. of the Delaware Statutes. The following are useful excerpts from the Delaware Statutes relating to the Delaware Advance Health Care Directive FormInformation and Instructions Delaware Living Will This package contains (1) Information and Instruction for Delaware Living Will Form; (2) Delaware Living Will Form. This Delaware Living Will is based Delaware