 | Delaware Medical Power of Attorney Form |
The Delaware Medical Power of Attorney Form is a written document by the Principal to authorize permission to an Attorney In Fact/Agent to act on their behalf in the event of incompetence, incapacity or major disability. It is generally employed to designate a responsible party in case of an anticipated or feared form of disability. The power may pass to the agent immediately or it may become effective only in the event the individual becomes incapacitated or disabled. This document is designed to survive the incapacity of the principal. It is personal because it relates only to medical matters not routine business matters. This document allows one person, the principal only, to allow the power of authority to another person. This document may be revoked in writing to the agent any time. (See Delaware Title 12 § 4904)
How To Write
1 – Preliminary Setup
Begin by downloading the document from this page and reading the fist section named “Advanced Health Care Directive”
2 – Instructions for Health Care Decisions
The Principal must read the instructions provided on page two, then enter his or her name into the final line.
3 – End of Life Instructions
This section will ask that the Principal read each section and only check the sections that would apply to their wishes. Begin by selecting from the following:
- Initial the blank space in item 1 if the Principal wishes to prolong life limited only by common health care standards
- If the Principal does not wish to prolong his or her life in the face of an terminal condition, then he or she must place a check on the blank spaces corresponding with the applicable statements:
- To define the Principal’s wishes, in the event he or she faces a fatal medical condition, check the statement beginning with “(i) I have a terminal condition…” If so, then each item listed (Artificial nutrition, Hydration through a conduit, Cardiopulmonary resuscitation, Mechanical respiration) should have either a check mark in the first column to signify Principal approval or a check mark in the second column to indicate a Principal restriction
- If the Principal wishes to define what is used in the even he or she becomes permanently unconscious, check the space preceding the words “(ii) I become permanently…” If so, the Principal will need to indicate a treatment approval by marking the first column or a treatment restriction by marking the second column for each item defined (Artificial Nutrition, Hydration, Cardiopulmonary resuscitation, or define one next to “Other”).
5 – Additional Considerations
Issues concerning relief from pain and any other directives stated by the patient:
- If the Principal has specific medical directives, enter them into the lines provided, if more room is needed, add a sheet and attach it to the form
- Again, enter the name of the Principal on the final line at the bottom of the page
6 – Part II: Power of Attorney For Health Care
Read the conditions in this section. If you agree, then you shall appoint your agent by presenting his or her information on the appropriately labeled spaces in the following order starting with the first blank space in the paragraph labeled as “A. Designation of Agent:”
- Print the name of the primary Agent or Attorney-in-Fact
- Enter the name of the alternate Agent or Attorney-in-Fact
- The Agent’s Physical Address must be supplied with each component in the properly labeled area (address, city, state, zip code)
- The Agent’s Home Phone Number and Daytime Number must be presented on the next line in the appropriate areas
- work phone
- The name of the alternate Agent may be printed on the line “name of individual you choose as alternate Agent”
- Report the Address of the alternate Agent on the blank line below the alternate Agent’s Name
- The current Home and Work Telephone Numbers of the alternate agent must be supplied on the last line in this section
7 – Agent’s Authority
The Principal and Agent must read this section, numbers 1-6 as well as (C) and (D) – If the Principal would like to strike through ANY of the language, they may feel free to do so. All strike throughs must be made before the signing of this document.
8 – Part III. Anatomical Gift Declaration
The Principal will read the information with regard to anatomical donation(s), then check the boxes he or she wishes to include in these instructions – Additional information may be placed on the blank lines provided – Select from the following:
- To define the donations, locate the words “I give,” then place a mark in the appropriate boxes (my body, any needed organs or parts, the following organs or parts defined by the Principal).
- The Principal may define where these donations should go by marking the choices indicating the donation may go to the physician at the time of death, the hospital, or defining a specific place after the word “to”
- Locate the words “for the following purpose” then indicate if donations may be made for any purpose, therapy, medical education, transplantation, or research by marking that choice’s corresponding check box
9 – Principal Signature Of Approval
Once this form has been completed, the Principal must provide the following:
- The Date this document is being signed in the space on the left
- His or her signature on the first line in the column on the right
- The Principal’s printed name must be presented below the signature
- The next two lines must be used to report the Principal’s Address
- The Principal must print his or her name at the bottom of this form
8 – Statement of Witnesses
This section must be reviewed by two witnesses. If the Principal is in a residence related to his or her health care, the Witnesses present must print their names in part C (this may be left blank if it is not the case). Each Witness must verify his or her presence at signing by satisfying one of the columns’ requirements:
- The Witness’ printed name must be displayed on the first line
- Record the Witness Address on the second line and third lines
- The fourth line requires the Witness Signature and Signature Date
9 – Optional Notarization
It is highly recommended by the state that you use a notary or a notary in addition to witnesses to fully certify this document’s authenticity. The last section is provided for the use of the Notary:
- The notary would will complete their commissioned information and affix their state seal
