Sample Advance Health Care Directive

PART I: INSTRUCTIONS FOR HEALTH CARE DECISIONS

END OF LIFE INSTRUCTIONS

Choice to Prolong Life

I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

OR

Choice Not to Prolong Life

I do not want my life to be prolonged if (check all that apply):

(1) I have a terminal condition (an incurable condition from which there is no reasonable medical expectation of recovery and which will cause my death, regardless of the use of life-sustaining treatment). In this case, I give the specific directions indicated:

(2) 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 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 the following, I give the specific directions indicated:

RELIEF FROM PAIN: Whether I choose 1 or 2 above, or neither, I direct that in all cases I be given all medically appropriate care necessary to make me comfortable and alleviate pain.

OTHER MEDICAL INSTRUCTIONS: If you wish to add to the instructions you have given above, you may do so here.

PART II: POWER OF ATTORNEY FOR HEALTH CARE

Your agent may make any health care 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 institution where you are receiving care.

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.

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 authorized as follows:

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 other procedures that affect any bodily function;

To have access to medical records and information to the same extent that I am entitled to, including the right to disclose the contents to others;

To authorize my admission to or discharge from any hospital, nursing home, residential care, assisted living, or similar facility or service;

To contract for any health care related service or facility on my behalf, without my agent incurring personal financial liability for such contracts;

To hire and fire medical, social service, and other support personnel responsible for my care;

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 intentionally cause) my death.

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.

Agent's Obligation: 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 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 interest, my agent shall consider my personal values to the extent known to my agent.

PART III. ANATOMICAL GIFT DECLARATION (Optional)

I hereby make the following anatomical gift(s) to take effect upon my death. The marks in the appropriate squares and words filled into the blanks below indicate my desires:

Effect of Copy: A copy of this form has the same effect as the original. I understand the purpose and effect of this document.

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 request, and in the presence of each other, have hereunto subscribed our names as witnesses, and state:

The Declarant is mentally competent.

That neither of us is prohibited by §2503 of Title 16 of the Delaware Code from being a witness.

Neither of us:

Is related to the declarant by blood, marriage or adoption;

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, is so entitled by operation of law then existing;

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.

Has a direct financial responsibility for the declarant's medical care;

Has a controlling interest in or is an operator or an employee of a health care institution in which the declarant is a patient or resident;

Is under eighteen years of age.

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 Guardian.

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