Del. Code tit. 16 § 2505
The following form may, but need not, be used to create an advance
health-care 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 the following form:
ADVANCE HEALTH-CARE DIRECTIVE
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 decisions for you.
This form lets you do either or both of these things. It also lets you 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 form.
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 decisions. 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 controlling 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/injury 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 agent's authority, your agent will
have the right to:
maintain, diagnose or otherwise affect a physical or mental condition unless
it's a life-sustaining procedure or otherwise required by law.
If you have a qualifying condition, your agent may make all health-care
decisions for you, including, but not limited to:
limited to, cardiopulmonary resuscitation and orders not to resuscitate.
and hydration and all other forms of health care.
Part 2 of this 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 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 to write out any additional instructions for
other than end of life decisions.
Part 3 of this form lets you express an intention to donate your bodily organs
and tissues following your death.
Part 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 individuals 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 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 responsibility.
You have the right to revoke this advance health-care directive or replace
this form at any time.
PART 1: POWER OF ATTORNEY FOR HEALTH CARE
make health-care decisions for me:
______________________________________________________________
(name of individual you choose as agent)
______________________________________________________________
(address) (city) (state) (zip code)
______________________________________________________________
(home phone) (work 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: ________________________________________
(name of individual you choose as first alternate agent)
_______________________________________________________________
(address) (city) (state) (zip code)
_______________________________________________________________
(home phone) (work phone)
OPTIONAL: If I revoke the authority of my agent and first 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:
________________________________________________________________
(name of individual you choose as second alternate agent)
________________________________________________________________
(address) (city) (state) (zip code)
________________________________________________________________
(home phone) (work phone)
authorized 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-care decisions for me,
except as I state here:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
(Add additional sheets if necessary.)
effective when my primary physician determines I lack the capacity to make my
own health-care decisions. As to decisions concerning the providing,
withholding and withdrawal of life-sustaining procedures my agent's authority
becomes effective when my primary physician determines I lack 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.
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 are 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
values to the extent known to my agent.
for me by a court, (please check one):
[ ] I nominate the agent(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:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
[ ] I do not nominate anyone to be guardian.
PART 2: INSTRUCTIONS FOR HEALTH CARE
If you are satisfied to allow your 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
want.
health-care providers and 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 check 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 from which, despite the application of
life-sustaining procedures, there can be no recovery) and regarding artificial
nutrition and hydration,
I make the following specific directions: I want used I do not want used
Artificial nutrition through a conduit ________ ________
Hydration through a conduit ________ ________
________ (ii) I become permanently unconscious (a medical 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 of 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 hydration,
I make the following specific directions: I want used I do not want used
Artificial nutrition through a conduit ________ ________
Hydration through a conduit ________ ________
Choice To Prolong Life
________ I want my life 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 of pain or discomfort be provided at all times, even if it
hastens my death:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
(Add additional sheets if necessary.)
PART 3: ANATOMICAL GIFTS AT DEATH
(OPTIONAL)
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 needed 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; [ ] the following named physician,
hospital, storage bank or other medical institution; [ ] the following
individual for treatment; for the following purposes: [ ] any purpose
authorized by law; [ ] transplantation; [ ] therapy; [ ] research; [ ]
medical education.
PART 4: PRIMARY PHYSICIAN
(OPTIONAL)
_____________________________________________________________________
(name of physician)
_____________________________________________________________________
(address) (city) (state) (zip code)
_____________________________________________________________________
(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 physician:
_____________________________________________________________________
(name of physician)
_____________________________________________________________________
(address) (city) (state) (zip code)
_____________________________________________________________________
(phone)
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 health care or, in the absence of a designation or if the
designated physician is not reasonably available, a physician who undertakes
the responsibility.
effect of this document.
________________ ________________________
(date) (sign your name)
________________ ________________________
(address) (print your name)
________________________________________________
(city) (state) (zip code)
Statement Of Witnesses
SIGNED AND DECLARED by the above-named declarant as and for the declarant's
written declaration under 16 Del.C. §§ 2502 and 2503, in our presence, who in
the declarant's presence, at the declarant's request, and in the presence of
each other, have hereunto subscribed our names as witnesses, and state:
the declarant 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;
present or inchoate claim against any portion of the estate of the declarant;
residential long-term health-care institution in which the declarant is a
resident; or
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 Department of Health and Social Services
First witness Second Witness
______________________________________________________________________
(print name) (print name)
_______________________________________________________________________
(address) (city, state, zip code) (address) (city, state, zip code)
_______________________________________________________________________
(signature of witness) (date) (signature of witness) (date)
I am not prohibited by § 2503 of I am not prohibited by § 2503 of
Title 16 of the Delaware Code Title 16 of the Delaware Code
from being a witness. from being a witness.
from being a witness. from being a witness.
16 Del. C. § 2505