Advance Health Care Directive of ________________________________________________________ Page 5
6. To authorize, or refuse to authorize, any medication or procedure intended to relieve
pain, even though such use may lead to physical damage, addiction, or hasten the moment of
(but not intent ionally cause) m y death.
C. WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes
effective when my attending physician determines I lack the capacity to make my own health
D. AGENT’S OBLIGATION: My agent shall m ake health car e decisions for me in accor dance
with this power of attorney for health care, any instructions I give in Part I of this form, and my
other wishes to the extent known to my agent. To the extent my wishes are unknown, health
care decisions by my agent shall conform as closely as possible to what I would have done or
intended under the circumstances. If my agent is unable to determine what I would have done
or intended under the circumstances, my agent will make health care decisions for me in
accordance with what my agent determines to be my best interest. In determining my best
inter est , my ag ent shall consider my personal values to t he extent known to my agent.
PART III. ANATOMICAL GIFT DECLARATION (Optional)
I hereby make the f ollowing anatomical gift(s) to take ef fect upon my death. The marks
in the appr opr iat e squares and words f illed into t he blanks below indicate my desires:
I give [ ] m y body; [ ] any needed org ans or part s;
[ ] t he following organs or part s _________________________________________
to [ ] the physician in attendance at m y death; [ ] the hospit al in which I die;
[ ] t he following nam ed physician, hospit al, st or age bank or ot her m edical instit ut ion
for t he following pur pose( s) :
[ ] any purpose aut hor ized by law; [ ] t ransplant at ion;
[ ] therapy; [ ] research;
[ ] m edical education.
EFFECT OF COPY: A copy of t his form has t he sam e effect as the or iginal.
I under st and t he pur pose and effect of this docum ent .
(date) (si gn your name)
(print your name)
(city) (state) (zip c ode )
STATEMENT OF WITNESSES
SIGNED AND DECLARED by the above-named declarant as and for his/her written
declaration under 16 Del.C. §§ 2502, 2503, in our presence, who in his/her presence, at his/her