Maryland Medical Power of Attorney Form

An individual anticipating her/his incapacitation in the future can grant the MPOA to a trustworthy person. The person granted with the MPOA will become responsible for the medical matters/decisions concerning the incapacitated individual.Download

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Your Durable Power of Attorney for Health Care,  Living Will and Other Wishes  I, ____________________ write this document as a directive regarding my medical care.     Put the initials of your name by the choices you want.  PART 1. MY DURABLE POWER OF ATTORNEY FOR HEALTH CARE ______I appoint this person to make decisions about my medical care if there ever comes a time when I cannot make those decisions myself:  NAME_________________________________PHONE: HOME __________________WORK______________________________ ADDRESS__________________________________________________________________________________________________  If the person above can’t or will not make decisions for me, I appoint this person:  NAME_________________________________PHONE :HOME___________________WORK______________________________ ADDRESS__________________________________________________________________________________________________  _____I have not appointed anyone to make health care decisions for me in this or any other document.  I want the person I have appointed, my doctors, my family, and others to be guided by the decisions I have made below:  PART 2. MY LIVING WILL     These are my wishes for my future medical care if there ever comes a time when I can’t make these decisions for myself.  A.  These are my wishes if I have a terminal condition:       Life-Sustaining Treatments  _____ I do not want life-sustaining treatments (including CPR) started.  If life

sustaining treatments are started, I want them stopped.      _____ I want life-sustaining treatments that my doctors think are best for me. _____ Other wishes: ___________________________________________________  Artificial Nutrition and Hydration  _____ I do not want artificial nutrition and hydration started if it would be the main treatment keeping me alive. If artificial nutrition and hydration is strated, I want it stopped.      ______ I want artificial nutrition and hydration even if it is the main treatment keeping me alive. ______ Other wishes: __________________________________________________  Comfort Care  ______ I want to be kept as comfortable and free of pain as possible, even if such care prolongs my dying or shortens my life. ______ Other wishes: __________________________________________________  B. These are my wishes if I am ever in a persistent vegetative state:     Life-Sustaining Treatments  _______ I do not want life-sustaining treatments (including CPR) started.  If lifesustaining treatments are started, I want them stopped.     _______ I want life-sustaining treatments that my doctors think are best for me.     _______ Other wishes:__________________________________________________  Artificial Nutrition and Hydration  _______ I do not want artificial nutrition and hydration started if it would be the main treatment keeping me alive. If artificial nutrition and hydration is started, I want it stopped. _______ I want artificial nutrition and hydration even if it is the main treatment keeping me alive. _______ Other wishes:__________________________________________________  Comfort Care  _______ I want to be kept as comfortable and free of pain as possible even if such care prolongs my dying or shortens my life. _______ Other wishes: __________________________________________________  C. Other Directions  You have the right to be involved in all decisions about your medical care, even those not dealing with terminal conditions or persistent vegetative states. If you have wishes not covered in other parts of this document please indicate them here:  PART 3. OTHER WISHES  A. Organ Donation

_______ I do not wish to donate any of my organs or tissues.       _______ I want to donate all of my organs and tissues. _______ I only want to donate these organs and tissues:________________________ _______ Other wishes:__________________________________________________  Autopsy  _______ I do not want any autopsy. _______ I agree to an autopsy if my doctors wish it. _______ Other wishes:__________________________________________________  If you wish to say more about any of the above choices, or if you have any other statements to make about your medical care, you may do so on a separate sheet of paper.  If you do so, put here the number of pages you are adding:____  PART 4. SIGNATURE  You and two witnesses must sign this document for it to be legal.  A. Your Signature       By my signature below I show that I understand the purpose and the effect of this document.  NAME________________________________________________________________________DATE____________________  ADDRESS___________________________________________________________________________  B. Your Witnesses’ Signature  I believe the person who has signed this advance directive to be of sound mind, that he/she signed or acknowledged this advance directive in my presence, and that he/she      appears not be acting under pressure, duress, fraud or undue influence.  I am not related to the person making this advance directive by blood, marriage or adoption, nor, to the best of my knowledge am I named in his/her will. I am not the person      appointed in this advance directive.  I am not a health care provider or an employee of health care provider who is now, or ahs been in the past, responsible for the care of the person making this advance directive.  Witness#1           NAME_______________________________________________________________________DATE____________________  ADDRES_______________________________________________________________________________________________  Witness#2            NAME_______________________________________________________________________DATE____________________  ADDRESS_____________________________________________________________________________________________