((Advanced Health Care Directive Brochure Text)) Advance Health Care Directive Instructions To give instructions about your own health care. To name someone else to make health care decisions for you. Delaware Health and Social Services Division of Services for Aging and Adults with Physical Disabilities You have the Right To give instructions about your own health care. To name someone else to make health care decisions for you. The Advance Health Care Directive form lets you do either or both of these things. The Advance Health Care Directive form also lets you express your wishes regarding anatomical gifts. The Advance Health Care Directive form does not contain all of the choices permitted under Delaware law. Because it is only a form, it may not contain language that applies to your specific circumstances. If you wish to modify the form, you may want to consult with a private lawyer. After you complete the Advance Health Care Directive form, clip this card and keep it in your wallet. Attention Health Care Providers: I have an Advance Health Care Directive My health care agent is: Name: Address: Phone: Please consult this document and/or my health care agent. Signature: (Title) Completing an Advance Health Care Directive Form Part 1 of this form lets you give specific instructions about health care decisions. Choices are provided for you to express your wishes regarding the provision, withholding, or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration as well as the provision of pain relief. These choices take effect only if you are in a “qualifying condition.” A “qualifying condition” is either a terminal condition or permanent unconsciousness. Part II of this form is a Power of Attorney for Health Care. Part II lets you name another individual as agent to make health care decisions for you, if a physician determines you lack the capacity to make your own health care 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 be an operator or employee of a residential long-term health care facility at which you are receiving care. If you are not in a terminal condition or in a permanently unconscious state, your agent may make all health care decisions for you except for decisions to provide, withhold or withdraw a life sustaining procedure. Unless you limit the agent’s authority, your agent will have the right to: Consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose, or otherwise affect a physical or mental condition unless it is a life sustaining procedure or otherwise required by law. Select or discharge health are providers and health care institutions. If you are in a terminal condition or are in a permanently unconscious state, your agent may make all health care decisions for you including but not limited to: The decisions listed above. Consent or refuse consent to life sustaining procedures such as, but not limited to, cardiopulmonary resuscitation and order not to resuscitate. Direct the providing, withholding, or withdrawing of artificial nutrition and hydration and all other forms of health care. When giving additional instructions, remember that your agent is required to follow your wishes. Since it is impossible to predict all medical situations, it is important you do not limit your agent in ways you do not intend. Part III of this form lets you express an intention to donate your bodily organs and tissues following your death. After completing this form, sign and date the form at the end. It is required that two other individuals sign as witnesses. Although not required, it is recommended that you sign in the presence of a notary public. 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 advance health care directive or replace this form at any time. Completing an Advance Health Care Directive form is strictly voluntary. If you have not given advance instructions for your health care or have not named an agent in a health care power of attorney and you become unable to make your own health care decisions, a surrogate will be asked to make those decisions for you. In most cases a surrogate is a member of your family. The persons listed below will be asked to assume the role of a surrogate in the following priority order: 1) Spouse 2) An adult child 3) A parent 4) An adult brother or sister 5) An adult grandchild 6) Niece or nephew 7) An adult who has exhibited special care and concern for the patient, if appointed as guardian for that purpose, by the Court of Chancery. The entire Death with Dignity Act is found in Title 16, Chapter 25 of the Delaware Code.