Delaware Code Title 16. Health and Safety § 2511. Optional form

1. NAMING AN AGENT

I want the following person to make health-care decisions for me if I cannot make decisions for myself:

Name:

Optional contact information (it is helpful to include information such as address, phone, and email):

2. NAMING AN ALTERNATE AGENT

I want the following person to make health-care decisions for me if I cannot and my Agent is not able or available to make them for me:

Name:

Optional contact information (it is helpful to include information such as address, phone, and email):

3. LIMITING YOUR AGENT'S AUTHORITY

I give my Agent the power to make all health-care decisions for me if I cannot make those decisions for myself, except the following:

(If you do not add a limitation here, your Agent will be able make all health-care decisions that an Agent is permitted to make under State law.)

1. INSTRUCTIONS ABOUT LIFE-SUSTAINING TREATMENT

This section gives you the opportunity to say how you want your Agent to act while making decisions for you.  You may mark or initial each choice.  You also may leave any choice blank.

Treatment.  Medical treatment needed to keep me alive but not needed for comfort or any other purpose should (mark or initial all that apply):

(___) Always be given to me.  (If you mark or initial this choice, you should not mark or initial other choices in this “treatment” section.).

(___) Not be given to me if I have a condition that is not curable and is expected to cause my death soon, even if treated.

(___) Not be given to me if I am unconscious and I am not expected to be conscious again.

(___) Not be given to me if I have a medical condition from which I am not expected to recover that prevents me from communicating with people I care about, caring for myself, and recognizing family and friends.

(___) Other (write what you want or do not want):

Food and liquids.  If I can't swallow and staying alive requires me to get food or liquids through a tube or other means for the rest of my life, then food or liquids should (mark or initial all that apply):

(___) Always be given to me.  (If you mark or initial this choice, you should not mark or initial other choices in this “food and liquids” section).

(___) Not be given to me if I have a condition that is not curable and is expected to cause me to die soon, even if treated.

(___) Not be given to me if I am unconscious and am not expected to be conscious again.

(___) Not be given to me if I have a medical condition from which I am not expected to recover that prevents me from communicating with people I care about, caring for myself, and recognizing family and friends.

(___) Other (write what you want or do not want):

(___) Pain relief.  If I am in significant pain, care that will keep me comfortable but is likely to shorten my life should (mark or initial all that apply):

(___) Always be given to me.  (If you mark or initial this choice, you should not mark or initial other choices in this “pain relief” section.)

(___) Never be given to me.  (If you mark or initial this choice, you should not mark or initial other choices in this “pain relief” section.)

(___) Be given to me if I have a condition that is not curable and is expected to cause me to die soon, even if treated.

(___) Be given to me if I am unconscious and am not expected to be conscious again.

(___) Be given to me if I have a medical condition from which I am not expected to recover that prevents me from communicating with people I care about, caring for myself, and recognizing family and friends.

(___) Other (write what you want or do not want):

2. MY PRIORITIES

You can use this section to indicate what is important to you, and what is not important to you.  This information can help your Agent make decisions for you if you cannot.  It also helps others understand your preferences.

You may mark or initial each choice.  You also may leave any choice blank.

Staying alive as long as possible even if I have substantial physical limitations is:

(___) Very important

(___) Somewhat important

(___) Not important

Staying alive as long as possible even if I have substantial mental limitations is:

(___) Very important

(___) Somewhat important

(___) Not important

Being free from significant pain is:

(___) Very important

(___) Somewhat important

(___) Not important

Being independent is:

(___) Very important

(___) Somewhat important

(___) Not important

Having my Agent talk with my family before making decisions about my care is:

(___) Very important

(___) Somewhat important

(___) Not important

Having my Agent talk with my friends before making decisions about my care is:

(___) Very important

(___) Somewhat important

(___) Not important

3. OTHER INSTRUCTIONS

You can write in this section more information about your goals, values, and preferences for treatment, including care you want or do not want.  You can also use this section to name anyone who you do not want to make decisions for you under any conditions.

1. OPTIONAL SPECIAL POWERS

My Agent can do the following things ONLY if I have marked or initialed them below:

(___) Admit me as a voluntary patient to a facility for mental health treatment for up to __________days (write in the number of days you want like 7, 14, 30 or another number).

(If I do not mark or initial this choice, my Agent MAY NOT admit me as a voluntary patient to this type of facility.)

(___) Place me in a nursing home for more than 100 days even if my needs can be met somewhere else, I am not terminally ill, and I object.

(If I do not mark or initial this choice, my Agent MAY NOT do this.)

2. ACCESS TO MY HEALTH INFORMATION

My Agent may obtain, examine, and share information about my health needs and health care if I am not able to make decisions for myself.  If I mark or initial below, my Agent may also do that at any time my Agent thinks it will help me.

(___) I give my Agent permission to obtain, examine, and share information about my health needs and health care whenever my Agent thinks it will help me.

3. FLEXIBILITY FOR MY AGENT

Mark or initial below if you want to give your Agent flexibility in following instructions you provide in this form.  If you do not, your Agent must follow the instructions even if your Agent thinks something else would be better for you.

4. NOMINATION OF GUARDIAN

You can say who you would want as your guardian if you needed one.  A guardian is a person appointed by a court to make decisions for someone who cannot make decisions.  Filling this out does NOT mean you want or need a guardian.  There is no guarantee that the court will appoint the person you want as guardian.

If a court appoints a guardian to make personal decisions for me, I want the court to choose:

(___) My Agent named in this form.  If my Agent cannot be a guardian, I want the Alternate Agent named in this form.

(___) Other (write who you would want and their contact information):