Health Care Power of Attorney Form - Delaware

Advance Health Care Directive of ________________________________________________________ Page 3
A. END OF LIFE INSTRUCTIONS
1. Choice To Pr olong Life
_____I want my life t o be pr olonged as long as possible within the lim its of generally
accepted healt h car e st andar ds.
OR
2. Choice Not To Prolong Life
I do not want my life t o be prolonged if (please check all t hat apply)
____ (i) I have a ter minal condit ion (an incurable condit ion from which there is no
reasonable m edical expectat ion of r e covery and wh ich will cause my death, regar dless
of t he use of life- sust aining t reat m ent ) . I n t his case, I give the specific dir ections
indicated:
I want used I do not want used
Art ificial nut r it ion t hr ough a conduit _______ _______
Hydration through a conduit _______ _______
Cardiopulm onar y resuscit at ion _______ _______
Mechanical respir at ion _______ _______
Ot her ( explain) ________________ _______ _______
____________________________
_____ (ii) I become permanently unconscious (a medical condition that has existed at
least four (4) weeks and has been diagnosed in accordance with currently accepted
medical standards and with reasonable medical certainty as total and irr ever sible loss of
consciousness and capacity for interaction with the environment. The term includes,
without limitation, a persistent vegetative state or irreversible coma) and regarding the
following, I give the specific direct ions indicat ed:
I want used I do not want used
Art ificial nut r it ion t hr ough a conduit _______ _______
Hydration through a conduit _______ _______
Cardiopulm onar y resuscit at ion _______ _______
Mechanical respir at ion _______ _______
Ot her ( explain) ________________ _______ _______
____________________________
B. RELIEF FROM PAIN: W hether I choose A.1 or A.2, or neither, I direct that in all cases I
be given all medically appropriate car e necessar y to m ake me com fort able and alleviate pain.
C. OTHER MEDICAL INSTRUCTION: If you wish to add to the instructions you have given
above, you may do so here.
_________________________________________________________________________________
_________________________________________________________________________________
(use additional sheets if necessary)
Page 3/6
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Health Care Power of Attorney Form - Delaware PDF

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