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Delaware Advance Directive Form

A Delaware advance directive is a form that allows someone to name someone else to make healthcare decisions for them. This is useful when a person becomes incapable of making their own decisions. The designated agent will have the right to consent or refuse consent to any care, treatment, service, or procedure, as well as to select or discharge healthcare providers.

Signing Requirements (§ 2503(b)) – Two (2) witnesses.

Statutory Form

ADVANCE HEALTH-CARE DIRECTIVE

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

[NAME]

(2) AGENT’S AUTHORITY: If I am not in a qualifying condition my agent is 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:

[EXCEPTIONS]

(3) 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.

(4) 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 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.

(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed 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:

[NAME(S)]

[◻] I do not nominate anyone to be guardian.

(6) END-OF-LIFE DECISIONS: If I am in a qualifying condition, I direct that my 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 and regarding artificial nutrition and hydration,
        • Artificial nutrition or hydration through a conduit: ______________________________________________________
      • ◻ (ii) I become permanently unconscious and regarding artificial nutrition and hydration,
        • Artificial nutrition or 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:

[EXCEPTIONS]

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

Signature ________________________

(8) SIGNATURES OF WITNESSES:

First witness ________________________

Second witness ________________________

I am not prohibited by § 2503 of Title 16 of the Delaware Code.