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Delaware _________________________ Address: ______________________________________ Date: _________________________________________ -7- _____________ -6- I am not prohibited by § 2503 of Title 16 of the Delaware Code from being a witness. _____________________________________________ (Second Witness Signature) Print Name: _____________________________________________________ (First Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Date: ____________________________ 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 the Delaware Code from being a witness. __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 ombudsmanr 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 declarant is a resident of a sanitarium, esent 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 controlling interest in or is an operatoor, 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 of the advance health-care directive, a pr 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 declarant or codicil thereto then existing nwho 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 Declarant is mentally competent. B. That neither__ -5- (11) SIGNATURES OF WITNESSES: Statement Of Witnesses SIGNED AND DECLARED by the above-named declarant as and for his/her written declaration under 16 Del.C. §§ 2502 and 2503, in our presence, : _____________________________________ __________________________________________ (Declarant's Signature) Print Name: ___________________________________ Address: ____________________________________the responsibility. (9) EFFECT OF COPY: A copy of this form has the same effect as the original. (10) SIGNATURE: Sign and date the form here: I understand the purpose and effect of this document. Dateor 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 available, a physician who undertakes tate) (zip code) _____________________________________________________________________________ (phone) Primary Physician shall mean a physician designated by an individual or the individual's agent ian: _____________________________________________________________________________ (name of physician) _____________________________________________________________________________ (address) (city) (s______ (phone) OPTIONAL: If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following physician as my primary physicof physician) _____________________________________________________________________________ (address) (city) (state) (zip code) _______________________________________________________________________cation. -4- PART 3: PRIMARY PHYSICIAN (OPTIONAL) (8) I designate the following physician as my primary physician: _____________________________________________________________________________ (name _; [ ] the following individual for treatment: __________________________ for the following purposes: [ [ [ [ [ ] any purpose authorized by law; ] transplantation; ] therapy; ] research; ] medical eduan in attendance at my death; [ ] the hospital in which I die; [ ] the following named physician, hospital, storage bank or other medical institution: _________________________________________________ks below indicate my desires. I give: [ ] my body; [ ] any needed organs or parts; [ ] the following organs or parts _________________________; To the following person or institutions [ ] the physici(OPTIONAL) (7) 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 squares and words filled into the blan__________________________________________________ ______________________________________________________________________________ (Add additional sheets if needed.) PART 2: ANATOMICAL GIFTS AT DEATH gree 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 direct that: _____________________________________________________________________________ __________________________________________________ [ ] I do not nominate anyone to be guardian. -3- (6) OTHER MEDICAL INSTRUCTIONS: (If you do not aagent(s) whom I named in this form in the order designated to act as guardian. [ ] I nominate the following to be guardian in the order designated: __________________________________________________ _all consider my personal 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 the extent my wishes are unknown, my agent shall make health-care decisio ns for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall make health-care decisions 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 capacity to make my 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 shlth-care decisions. As to decisions concerning the providing, withholding and withdrawal of lifesustaining procedures my agent's authority becomes effective when my primary physician determines I lack___ (Add additional sheets 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 heaare decisions for me, except as I state here: ______________________________________________________________________________ ___________________________________________________________________________ized to make all health-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-cp code) _____________________________________________________________________________ -2- (home phone) (work phone) (2) AGENT'S AUTHORITY: If I am not in a qualifying condition my agent is author___________________________________ (name of individual you choose as second alternate agent) _____________________________________________________________________________ (address) (city) (state) (ziirst alternate agent or if neither is willing, able, or reasonably available to make a health-care decision for me, I designate as my second alternate agent: ______________________________________________ (address) (city) (state) (zip code) _____________________________________________________________________________ (home phone) (work phone) OPTIONAL: If I revoke the authority of my agent and f_____________________________________________________________________ (name of individual you choose as first alternate agent) _________________________________________________________________________phone) OPTIONAL: If 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 llowing individual as my agent to make health-care decisions for me: _____________________________________________________________________________ (name of individual you choose as agent) ____________nsibility. You have the right to revoke this power of attorney for health care or replace this form at any time. PART 1: POWER OF ATTORNEY FOR HEALTH CARE (1) DESIGNATION OF AGENT: I designate the foreceiving care and 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 respoer individuals sign as witnesses. Give a copy of the signed and completed form to your physician, -1- to any other health-care providers you may have, to any health-care institution at which you are death. Part 3 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 otholding or withdrawal of artificial nutrition and hydration and all other forms of health care. Part 2 of this form lets you express an intention to donate your bodily organs and tissues following yourd in (a) and (b). (d) Consent or refuse consent to life sustaining procedures, such as, but not limited to, cardiopulmonary resuscitation and orders not to resuscitate. (e) Direct the providing, withhge health-care providers and health-care institutions; If you have a qualifying condition, your agent may make all health-care decisions for you, including, but not limited to: (c) The decisions listere, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition unless it's a life-sustaining procedure or otherwise required by law. (b) Select or dischart for decisions providing, withholding or withdrawing of a life sustaining procedure. Unless you limit the agent's authority, your agent will have the right to: (a) Consent or refuse consent to any castitution at which you are receiving care. If you do not have a qualifying condition (terminal illness/injury or permanent unconsciousness), your agent may make all health-care decisions for you excep, able or reasonably available to make decisions for you. Unless related to you, an agent may not have a controlling interest in or be an operator or employee of a residential long-term health-care in individual as agent to make health-care decisions for you if you become incapable of making your own decisions. You may also name an alternate agent to act for you if your first choice is not willing. If you 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 is a power of attorney for health care. Part 1 lets you name anothersions for you. This form lets you name someone else to make health-care decisions for you. It also lets you express your wishes regarding anatomical gifts and the designation of your primary physicianlforms.com -4- POWER OF ATTORNEY FOR HEALTH CARE EXPLANATION You have the right to give instructions about your own health care. You also have the right to name someone else to make health-care deciible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegag this document you should have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. Any possdvice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signin been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not intended and are not a substitute for legal and/or tax ahall be presumed to represent a suspension of an advance health-care directive while receiving such emergency treatment. [_] These forms are provided "as is" and no implied or express warranties havedvance health-care directive 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 son of marriage or a 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 a communicate the fact 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, dissolutises. This record shall 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 revoke done in the 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 witnesalth-care directive. (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 ton to be pregnant, so 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 hee. (i) A written advance 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 know by blood, marriage 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 carited to, the factors, if applicable, stated in this subsection. (g) A health-care decision made by an agent for a principal is effective witho ut judicial approval. (h) Unless related to the principales, the agent's decision 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 limto, statements made 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 circumstanc) The patient's likelihood 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 but not limited to, 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 possible to what 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, l instructions, if 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 asatient after consultation 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 individuaician to certify in 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 ph-care directive; 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 physdividual lacks or 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 healtacks capacity and 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 inive is to be applied 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 lnder this section 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 directn employee of a health 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 ute claim against 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 axecuting of the power 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 inchoaclarant by blood, 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 et or by another 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 demay authorize the 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 declaranly competent may: (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 s from the Delaware 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 mental Attorney for Health Care Form. This Delaware Power of Attorney for Health Care is based in part on Title 16 Chapter 25 Section 2503 et. Seq. of the Delaware Statutes. The following are useful excerptInformation and Instructions Delaware Power of Attorney for Health Care This package contains (1) Information and Instruction for Delaware Power of Attorney for Health Care Form; (2) Delaware Power of Delaware