Delaware Advance Directive Form (Medical POA + Living Will)

Delaware advance directive is a legal document that combines a living will and medical power of attorney. A medical power of attorney allows an individual to name an “agent” who can make healthcare decisions should said individual become incapacitated. A living will allows the individual to document their end-of-life wishes. The agent will only be asked to make decisions about healthcare in the event the individual is incapacitated.

Laws

Statutory Form§ 2505

Signing Requirements (§ 2503(b)) – Two (2) witnesses, neither of which may be a relative by blood, marriage, or adoption, entitled to any portion of the declarant’s estate, or have direct financial responsibility for the declarant.

State Definition (§ 2501(a)) – “Advance health-care directive” shall mean an individual instruction or a power of attorney for health care, or both.

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How To Write

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Part 1. Power Of Attorney For Health Care

Section 1. Designation Of Agent

(1) Name Of Delaware Health Care Agent. As the Principal in this document, you will appoint a Private Party to act in the State of Delaware on your behalf concerning your health care decisions. This person will use such powers to carry out the medical treatment instructions you deliver. The name of this Delaware Health Care Agent must be produced.

(2) Address Of Delaware Agent.

(3) Agent Telephone Numbers.

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(4) Alternate Agent. It is assumed that the Private Party acting as your Health Care Agent with Delaware Physicians bears your approval, is able to carry out this function, and is willing to act in this capacity. If any of these qualities change in the future then a previously set up Alternate Agent to automatically inherit the principal powers given to your Health Care Agent. Identify the Delaware  Alternate Agent by name. Bear in mind, this Party will not be considered a co-agent (unless you specifically state as much later in this paperwork). Instead, he or she will not have the ability or approval to represent you unless the Delaware Health Care Agent position becomes vacant.

(5) Address Of Alternate Agent.

(6) Phone Numbers.blank

(7) Second Delaware Alternate Agent. There may be scenarios where the Delaware Health Care Agent is unable or ineligible to act in your name and the Alternate Agent is either unavailable or unable to act on your behalf to give Delaware Physicians your directives. You can promote continuous representation by naming a Second Alternate Agent with the approval to take up the role of being your Health Care Representative by recording this Party’s name.

(8) Alternate Agent Address.

(9) Telephone Numbers.

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Section 2 Agent’s Authority

(10) Agent’s Non-Crisis Powers. By default, your Health Care Agent will have the ability to make medical decisions for you on a day-to-day basis regardless of your condition. If you wish your Health Care Agent to make only certain decisions and carry out specific health care directives in your name even when you are not incapacitated or suffering from a severe medical condition, then you must define these limitations. For instance, you may wish to restrict your Agent from committing you to new programs or medication plans.

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(11) Agent’s Powers When Incapacitated. This appointment also allows your Health Care Agent to represent your wishes to Delaware Medical Personnel when you are incapacitated, incognizant, or unconscious for an extended period of time. If you wish to limit or restrict the medical treatment decisions and acts that your Delaware Health Care Agent can engage in your name then you must state these restrictions in this document.

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Section 5. Nomination Of Guardian

(12) Option To Nominate Agent. This directive, if desired, can be used to cover the scenario of the courts assigning a Guardian to protect your health of your body when you are incapacitated. This usually results from extenuating circumstances, however if the State of Delaware determines this is necessary, then including a nomination for your Delaware Health Care Agent in this directive will usually be taken into consideration by the Delaware Courts handling this matter. Your initials next to the appropriate statement enables this option to be set.

(13) Non-Agent Nominations. If you do not wish to nominate your Delaware Health Care Agent to this role or if you wish to name multiple Nominations, then initial the second option and provide a the name of every person you wish to nominate in the order you wish them reviewed. 

(14) Waiving Your Nomination. If you have decided that you do not wish to nominate any Party for the role of Guardian should the Courts decide this necessary, then initial the third statement.

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Part 2 Instructions For Health Care

Section 6. End-Of-Life Decisions

(15) Life Prolonging Directive When Terminal. When you have been clearly diagnosed as hav ing a terminal condition that progressively debilitates your body as time goes on, the decision as to how much medical care you wish devoted to prolonging your life will require some attention. If you have determined as the Delaware Principal behind this paperwork, that you wish your life prolonged as long as possible with the tools and procedures at the disposal of Delaware Care Providers then, initial statement A of the living will portion of this directive package.

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(16) Refusing Life Support When Terminal. You have the option of deciding that medical care should not be geared toward prolonging your life if you are diagnosed with a terminal condition. If you prefer that Delaware Medical Care Providers focus their efforts and your treatment on comfort care, then statement B should be initialed and some additional preferences can be addressed.

(17) Artificial Nutrition Preference. The ability to discern your medical preferences when experiencing a terminal condition or incurable disease from those you hold when in a persistently unconscious state. Your decision as to whether you will accept artificial nutrition (delivered through an IV or a tube) when you are incapacitated or unable to take in nutrients and have an incurable medical condition can b e provided through your initials.

(18) Artificial Hydration Directive. Your initials should also be used to establish your preferences on artificial hydration when you are suffering from an untreatable or incurable medical condition when incapacitated and unable to take in liquids (i.e. a common problem with rabies).

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(19) Life Prolonging Directive When Persistently Unconscious. This directive can be used to inform Delaware Physicians who have determined that you are permanently unconscious, in a persistent vegetative state, or an irreversible coma (and have been for at least four weeks) of your  intent to deny life-prolonging treatment. This will require your initials presented for confirmation. It should be mentioned that if this item is left unapproved (without your initials presented) then Delaware Physicians may well assume you wish your life prolonged when in an irreversible coma.

(20) Artificial Nutrition Preference. Your approval is also needed to either accept artificial nutrition delivered when you are in an irreversible coma and unable to intake nutrients or needed to employ the directive to withhold artificial nutrition when you bear such a diagnoses.

(21) Artificial Hydration Directive. An additional level of consent is requested regarding the topic of artificial hydration and being in an irreversible coma. Be advised, that if you are in a coma and unable to drink, then death by dehydration is often imminent or unavoidable unless fluids are delivered to your body.

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Section 7. Relief From Pain Or Discomfort

(22) Instructions On Comfort Care. By default, this paperwork sets your medical directive to that of comfort care thus informing Delaware Medical Care Providers that you wish to be kept pain-free and as comfortable as possible at all times. However, if you wish to inform Delaware Health Care Professionals that some treatments and procedures used in pain management or comfort care do not bear your approval, then use the area supplied to present these restrictions.

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Section 8. Other Health Care Instructions Or Wishes

(23) Principal Concerns And Preferences. An area has also been reserved so that you can set additional medical concerns, preferences, and even refusals on paper for the benefit of attending Delaware Medical Personnel seeking your treatment preferences. An attachment with your medical preferences can also be named here as containing this information but must also be physically attached to this paperwork at all times before you, as the Delaware Principal, sign this directive to effect.

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Part 3. Anatomical gifts At DeathSection 9 Making An Anatomical Gift

(24) Preferred Donation. To declare that you wish to make anatomical gifts or organ donations, you must approve the level of donation you wish made. In this way you can approve of your entire body being an anatomical gift, of all of your organs and tissues, or only approve of certain body parts and organs that you list.

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(25) Authorized Recipients. The Parties or Entities that you wish to receive your anatomical gifts should be indicated as well. This form enables you to establish that your anatomical gifts should be made to the Physician attending at the time of death, the hospital where death occurs, a specific Physician or Institution that you name, or an individual that you name in this section as the intended Recipient of your anatomical gifts.

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(26) Approved Purpose(s). Your anatomical gifts can be made for any legal purpose specific reasons that you name by delivering your initials of approval by the desired item(s).

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Part 4. Designation Of Primary Physician

(27) Primary Physician Information. This directive can be utilized by Delaware Physicians to contact your primary or preferred Physician. This only requires a record of your Primary Physician’s Name, office address, and phone number(s).

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Section 12. Signature

(28) Delaware Principal’s Dated Signature. Your signature is required to set your medical instructions in motion. When you are ready to sign this paperwork, make sure to do so before two Witnesses to satisfy the requirements set by the State of Delaware. When you have gathered these Parties, record the current date then sign your name.

(29) Your Printed Name.

(30) Your Address.

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Section 13. Statement Of Witnesses

(31) Patient Advocate Or Ombudsman Status. The two Witnesses gathered will need to meet the requirements defined in the Witness statement. If one of them is a Patient Advocate or Ombudsman then his or her name must be reported as such before either of these Parties continue. This Party must act as a Witness if the Principal (You) is a Patient in an advance Care Facility, Sanitarium, Nursing Home, etc.

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(32) Dated Signature Of Witness 1. If the first Witness can  testify to the above statement as being true after watching you sign this document, then he or she must date and sign the area provided below the Witness statement.

(33) Witness 1 Information. The printed name and complete address of Witness 1 must also be produced by this Party once he or she has signed this area.

(34) Dated Signature Of Witness 2. The second Witness will also need to review the Witness statement then date and sign this form where requested.

(35) Witness 2 Information. Witness 2’s printed name and address are required for this document.

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