MAKE YOUR FREE Delaware Medical Power of Attorney

HEALTHCARE POWER OF ATTORNEY

EXPLANATION

This form is a power of attorney for health care, allowing you to 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 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 care, 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 discharge 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 listed 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, withholding, or withdrawal of artificial nutrition and hydration and all other forms of health care.

After completing this form, sign and date the form at the end. It is required that two 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 he or she understands your wishes and is willing to take the responsibility.

You have the right to revoke this health-care power of attorney or replace this form at any time.

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 a residential long-term care institution where you are receiving care. You may cross out any wording you do not want.

() DESIGNATION OF AGENT: I designate the following individual as my agent to make health-care decisions for me:

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Home Phone: Work Phone:

() AGENT'S AUTHORITY:

() 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 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.

() 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 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.

() NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I

() EFFECT OF COPY: A copy of this form has the same effect as the original.

() SIGNATURE: Sign and date the form here: I understand the purpose and effect of this document.

Date: ___________________________

____________________________________________

Signature

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() 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. Sections 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:

A. That the declarant is mentally competent.

B. That neither of us:

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 nor, 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 present or potential 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 operator 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, rest home, nursing home, boarding home, or related institution, one of us 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.

First Witness:

____________________________________________________

(Signature of Witness)(Date)

I am not prohibited by Section 2503 of Title 16 of the Delaware Code from being a witness.

Second Witness:

____________________________________________________

(Signature of Witness)(Date)

I am not prohibited by Section 2503 of Title 16 of the Delaware Code from being a witness.

Statement of Patient Advocate or Ombudsman

(If the declarant is a patient in a skilled nursing facility, one of the witnesses must be a patient advocate or ombudsman. The following statement is required only if the declarant is a patient in a skilled nursing facility, a health-care facility that provides the following basic services: skilled nursing care and supportive care to patients whose primary need is for availability of skilled nursing care on an extended basis. The patient advocate or ombudsman must sign the "Statement of Witnesses" above AND must also sign the following statement.)

I declare that I am a patient advocate or ombudsman as designated by the Division of Services for Aging and Adults with Physical Disabilities or the Public Guardian.

____________________________________________________

(Signature of patient advocate or ombudsman)(Date)