Maryland Living Will Form
If a person wishes to assign a representative who will make decisions regarding the kind of medical treatment they should receive in the case they are unable to decide that for themselves in the State of Maryland, the Maryland Living Will Form has to be completed and submitted.
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Page 1 of 8By
: \
Date of Birth:
(Print Name) (M onth/Day/Year)
Using this advance directive form to do health care planning is completely optional. Other
forms are also valid in Maryland. No matter what form you use, talk to your family and others
close to you about your wishes.
This form has two parts to state your wishes, and a third part for needed signatures. Part
I of this form lets you answer this question: If you cannot (or do not want to) make your own
health care decisions, who do you want to make them for you? The person you pick is called
your health care agent. Make sure you talk to your health care agent (and any back-up agents)
about this important role. Part II lets you write your preferences about efforts to extend your
life in three situations: terminal condition, persistent vegetative state, and end-stage condition.
In addition to your health care planning decisions, you can choose to become an organ donor
after your death by filling out the form for that too.
º You can fill out Parts I and II of this form, or only Part I, or only Part II. Use the form to
reflect your wishes, then sign in front of two witnesses (Part III). If your wishes change, make
a new advance directive. »
Make sure you give a copy of the completed form to your health care agent, your doctor,
and others who might need it. Keep a copy at home in a place where someone can get it if
needed. Review what you have written periodically.
PART I: S ELECTION OF HEALTH CARE AGENT
A. Selection of Primary Agent I select the following individual as my agent to make health care decisions for me:
Name: _______________________________________________________________________\
___
Address: ________________________________________________________________________\
_
________________________________________________________________________\
________
Telephone Numbers: ____________________________________________________________
(home and cell) M
ARYLAND ADVANCE DIRECTIVE :
P LANNING FOR FUTURE HEALTH CARE DECISIONS
Page 2 of 8
B. Selection of Back-up Agents
(Optional; form valid if left blank)
1. If my primary agent cannot be contacted in time or for any reason is unavailable or unable
or unwilling to act as my agent, then I select the following person to act in this capacity:
Name: _______________________________________________________________________\
___
Address: ________________________________________________________________________\
_
________________________________________________________________________\
________
Telephone Numbers: ____________________________________________________________
(home and cell)
2. If my primary agent and my first back-up agent cannot be contacted in time or for any reason are unavailable or unable or unwilling to act as my agent, then I select the following
person to act in this capacity:
Name: _______________________________________________________________________\
___
Address: ________________________________________________________________________\
_
________________________________________________________________________\
________
Telephone Numbers: ____________________________________________________________
(home and cell)
C. Powers and Rights of Health Care Agent I want my agent to have full power to make health care decisions for me, including the power
to:
1. Consent or not to medical procedures and treatments which my doctors offer, includingthings that are intended to keep me alive, like ventilators and feeding tubes;
2. Decide who my doctor and other health care providers should be; and
3. Decide where I should be treated, including whether I should be in a hospital, nursing home, other medical care facility, or hospice program.
4. I also want my agent to: a. Ride with me in an ambulance if ever I need to be rushed to the hospital; and
b. Be able to visit me if I am in a hospital or any other health care facility. THIS ADVANCE DIRECTIVE DOES NOT MAKE MY AGENT
RESPONSIBLE FOR ANY OF THE COSTS OF MY CARE .
Page 3 of 8
This power is subject to the following conditions or limitations:
(Optional; form valid if left blank)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
________________________________________________________________________\
__________
D. How my Agent is to Decide Specific Issues
I trust my agent’s judgment. My agent should look first to see if there is anything in Part II of this
advance directive that helps decide the issue. Then, my agent should think about the conversations
we have had, my religious and other beliefs and values, my personality, and how I handled medical
and other important issues in the past. If what I would decide is still unclear, then my agent is to
make decisions for me that my agent believes are in my best interest. In doing so, my agent should
consider the benefits, burdens, and risks of the choices presented by my doctors.
E. People My Agent Should Consult (Optional; form valid if left blank)
In making important decisions on my behalf, I encourage my agent to consult with the following
people. By filling this in, I do not intend to limit the number of people with whom my agent might
want to consult or my agent’s power to make decisions. Name(s) Telephone Number(s):
__________________________________________ ___________________________________
__________________________________________ ___________________________________
__________________________________________ ___________________________________
__________________________________________ ___________________________________
F. In Case of Pregnancy (Optional, for women of child-bearing years only; form valid if left blank)
If I am pregnant, my agent shall follow these specific instructions:
__________________________________________________________________________________\
__________________________________________________________________________________
________________________________________________________________________\
__________
G. Access to my Health Information – Federal Privacy Law (HIPAA) Authorization
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1. If, prior to the time the person selected as my agent has power to act under this document,
my doctor wants to discuss with that person my capacity to make my own health care
decisions, I authorize my doctor to disclose protected health information which relates to
that issue.
2. Once my agent has full power to act under this document, my agent may request, receive, and review any information, oral or written, regarding my physical or mental health,
including, but not limited to, medical and hospital records and other protected health
information, and consent to disclosure of this information.
3. For all purposes related to this document, my agent is my personal representative under the Health Insurance Portability and Accountability Act (HIPAA). My agent may sign, as my
personal representative, any release forms or other HIPAA-related materials.
H. Effectiveness of this Part (Read both of these statements carefully. Then, initial
one only.)
My agent’s power is in effect: 1. Immediately after I sign this document, subject to my right to make any decision aboutmy health care if I want and am able to. O__________
>>OR<<
2. Whenever I am not able to make informed decisions about my health care, eitherbecause the doctor in charge of my care (attending physician) decides that I have
lost this ability temporarily, or my attending physician and a consulting doctor
agree that I have lost this ability permanently.
O__________ If the only thing you want to do is select a health care agent, skip
Part II. Go to Part III to sign and have the advance directive
witnessed. If you also want to write your treatment preferences,
go to Part II. Also consider becoming an organ donor, using the
separate form for that.
Page 5 of 8P
ART II: T REATMENT PREFERENCES (“LIVING WILL ”)
A. Statement of Goals and Values (Optional: Form valid if left blank)
I want to say something about my goals and values, and especially what’s most important to me
during the last part of my life: \
\
\
\
\
\
\
\
B. Preference in Case of Terminal Condition
(If you want to state what your preference is, initial
one only. If you do not want to state a
preference here, cross through the whole section.)
If my doctors certify that my death from a terminal condition is imminent, even if life-
sustaining procedures are used:
1. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try to extend my life. I do not want to receive nutrition and fluids
by tube or other medical means.
O______________
>>OR<<
2. Keep me comfortable and allow natural death to occur. I do not want medical interventions used to try to extend my life. If I am unable to take enough nourishment by
mouth, however, I want to receive nutrition and fluids by tube or other medical means.
O______________
>>OR<<
3. Try to extend my life for as long as possible, using all available interventions that in reasonable medical judgment would prevent or delay my death. If I am unable to take
enough nourishment by mouth, I want to receive nutrition and fluids by tube or other
medical means.
O______________
Page 6 of 8
C. Preference in Case of Persistent Vegetative State (If you want to state what your preference is, initial
one only. If you do not want to state a
preference here, cross through the whole section.)
If my doctors certify that I am in a persistent vegetative state, that is, if I am not conscious
and am not aware of myself or my environment or able to interact with others, and there is
no reasonable expectation that I will ever regain consciousness:
1. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try to extend my life. I do not want to receive nutrition and fluids
by tube or other medical means. O______________
>>OR<<
2. Keep me comfortable and allow natural death to occur. I do not want medical interventions used to try to extend my life. If I am unable to take enough nourishment by
mouth, however, I want to receive nutrition and fluids by tube or other medical means. O______________
>>OR<<
3. Try to extend my life for as long as possible, using all available interventions that in reasonable medical judgment would prevent or delay my death. If I am unable to take
enough nourishment by mouth, I want to receive nutrition and fluids by tube or other
medical means.
O______________
D. Preference in Case of End-Stage Condition (If you want to state what your preference is, initial
one only. If you do not want to state a
preference here, cross through the whole section.)
If my doctors certify that I am in an end-state condition, that is, an incurable condition that
will continue in its course until death and that has already resulted in loss of capacity and
complete physical dependency:
1. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try to extend my life. I do not want to receive nutrition and fluids
by tube or other medical means. O______________
>>OR<<
2. Keep me comfortable and allow natural death to occur. I do not want medical interventions used to try to extend my life. If I am unable to take enough nourishment by
mouth, however, I want to receive nutrition and fluids by tube or other medical means. O______________
>>OR<<
3. Try to extend my life for as long as possible, using all available interventions that in reasonable medical judgment would prevent or delay my death. If I am unable to take
enough nourishment by mouth, I want to receive nutrition and fluids by tube or other
medical means.
O______________
Page 7 of 8
E. Pain Relief
No matter what my condition, give me the medicine or other treatment I need to relieve pain.
F. In Case of Pregnancy (Optional, for women of child-bearing years only; form valid if left blank)
If I am pregnant, my decision concerning life-sustaining procedures shall be modified as
follows: \
\
\
\
G. Effect of Stated Preferences (Read both of these statements carefully. Then, initial
one only.)
1. I realize I cannot foresee everything that might happen after I can no longer decide for myself. My stated preferences are meant to guide whoever is making decisions on my behalf and my
health care providers, but I authorize them to be flexible in applying these statements if they
feel that doing so would be in my best interest.
O______________
>>OR <<
2. I realize I cannot foresee everything that might happen after I can no longer decide for myself. Still, I want whoever is making decisions on my behalf and my health care providers to follow
my stated preferences exactly as written, even if they think that some alternative is better.
O______________
Page 8 of 8P
ART III: S IGNATURE AND WITNESSES
By signing below as the Declarant, I indicate that I am emotionally and mentally competent
to make this advance directive and that I understand its purpose and effect. I also
understand that this document replaces any similar advance directive I may have
completed before this date.
_______________________________________________ ________________________________
(Signature of Declarant) (Date)
The Declarant signed or acknowledged signing this document in my presence and, based
upon personal observation, appears to be emotionally and mentally competent to make this
advance directive.
__________________________________________________ ___________________________
(Signature of Witness) (Date)
_________________________________________________
Telephone N um ber(s):
_________________________________________________ ___________________________
(Signature of Witness) (Date)
_________________________________________________
Telephone N um ber(s):
( Note: Anyone selected as a health care agent in Part I may not be a witness. Also, at least
one of the witnesses must be someone who will not knowingly inherit anything from the
Declarant or otherwise knowingly gain a financial benefit from the Declarant’s death.
Maryland law does not require this document to be notarized.)
Page 1 of 2
By:
Date of Birth:
(Print Name) (M onth/Day/Year)
PART I: O RGAN DONATION
(Initial the ones that you want. Cross through any that you do not want.) Upon my death I wish to donate:
Any needed organs, tissues, or eyes. O______________
Only the following organs, tissues, or eyes: O______________ \
\
\
\
\
\
I authorize the use of my organs, tissues, or eyes:
For transplantation
O______________
For therapy O______________
For research O______________
For medical education O______________
For any purpose authorized by law O______________
I understand that no vital organ, tissue, or eye may be removed for transplantation
until after I have been pronounced dead. This document is not intended to change
anything about my health care while I am still alive. After death, I authorize any
appropriate support measures to maintain the viability for transplantation of my
organs, tissues, and eyes until organ, tissue, and eye recovery has been completed.
I understand that my estate will not be charged for any costs related to this
donation.
PART II: D ONATION OF BODY
After any organ donation indicated in Part I, I wish my body to be donated for use
in a medical study program.
O______________ A
FTER MY D EATH
(This document is optional. Do only what reflects your wishes.)
Page 2 of 2P
ART III: D ISPOSITION OF BODY AND FUNERAL ARRANGEMENTS
I want the following person to make decisions about the disposition of my body and
my funeral arrangements: (Either initial the first or fill in the second.)
The health care agent who I named in my advance directive. O______________
>>OR<<
This person: Name: \
Address: \
\
\
Telephone Number(s): \
(Home and Cell)
If I have written my wishes below, they should be followed. If not, the person I have
named should decide based on conversations we have had, my religious or other beliefs
and values, my personality, and how I reacted to other peoples’ funeral arrangements. My
wishes about the disposition of my body and my funeral arrangements are:
\
\
\
\
\
\
PART IV: S IGNATURE AND WITNESSES
By signing below, I indicate that I am emotionally and mentally competent to make this
donation and that I understand the purpose and effect of this document.
__________________________________________ ____________________________
(Signature of Donor) (Date)
The Donor signed or acknowledged signing the foregoing document in my presence and,
based upon personal observation, appears to be emotionally and mentally competent to
make this donation.
__________________________________________ ____________________________
(Signature of Witness) (Date)
__________________________________________
Telephone N o:
__________________________________________ ____________________________
(Signature of Witness) (Date)
__________________________________________
Telephone N o:
AFTER MY DEATH
Part II: Donation of Body
T he S tate A natom y B o ard, a unit of the D epartm ent of
H ealth and Mental Hygiene adm inisters a statewide B ody
D on a tion P rogram . A natom ical D onation allows
individuals to dedicate the use of their bodies upon death
to ad vance m edical education, clinical and allied-health
training and research study to M aryland’s m edical stu dy
institutions. T he A natom y B oard requires individ uals to
pre-register prior to death as an anatom ical d o n o r to the
state B ody D o n ation P rogram . T here are no m edical
restrictions or qualifications to becom ing an a “B ody
D ono r”. A t death the B oard will assum e the custody and
control of the body for study use. It is truly a le g a cy left
behind for others to have healthier lives. For donation
inform ation and form s you can contact the B oard toll-free
at 1-800.879.272 8
D id You R em em ber To ...
G Fill out Part I if you w ant to nam e a health care agent?
G N am e one or tw o back-up agents in case yo u r first
choice as health care age n t is not available w hen
needed?
G Talk to your ag e n ts and back-up agent about your
values an d priorities, and decide w hether that’s
enough guidance or w hether you also w ant to m ake
specific health care decisions in the advance
directive?
G If you w ant to m ake specific decisions, fill out Part II,
choosing carefully am ong alternatives?
G Sign and date the advance d irective in Part III, in
front of tw o w itnesses w ho also need to sign?
G Look over the “A fter M y D eath” fo rm to see if you
w ant to fill out any part of it?
G M ake sure your health care agent (if you nam ed one),
your fam ily, and your doctor know abou t your
advance care planning?
G G ive a copy of your advance directive to your health
care agent, fam ily m em bers, doctor, and hospital or
nursing hom e if you are a patient there?
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