2017 Maryland Code
Health - General
Title 5 - Death
Subtitle 6 - Health Care Decisions Act
Part I - Advance Directives.
§ 5-603. Suggested forms -- Living wills

• Planning for Future Health Care Decisions

• ____

  (Print Name)

  (Month/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.

  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.

• 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)

• 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 consent to medical procedures and treatments which my

      doctors offer, including things 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.

    I also want my agent to:

    • 1. Ride with me in an ambulance if ever I need to be rushed to the

      hospital; and

    • 2. 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.

    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

  or 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 these 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
  • 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 about my health care if I want and am able to.

      ____

      • ((or))
    • 2. Whenever I am not able to make informed decisions about my health care,

      either because 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.

      ____

      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, use Part II. Also consider

        becoming an organ donor, using the separate form for that.

• 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 your preference, 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.

        ____

        • ((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.

        ____

        • ((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.

        ____

• C. Preference in Case of Persistent Vegetative State
  • (If you want to state your preference, 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.

        ____

        • ((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.

        ____

        • ((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.

        ____

• D. Preference in Case of End-Stage Condition
  • (If you want to state your preference, 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-stage 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.

        ____

        • ((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.

        ____

        • ((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.

        ____

• 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.

    ____

    • ((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.

    ____

• 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 Number(s)

  ____

  ____

  (Signature of Witness)

  (Date)

  ____

  Telephone Number(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.)

  AFTER MY DEATH

  (This form is optional. Fill out only what reflects your wishes.)

  By:____ Date of Birth:

  • ____

    (Print Name)

    (Month/Day/Year)

• (Initial the ones that you want.)

  Upon my death I wish to donate:

  • Any needed organs, tissues, or eyes.

    ____

• Only the following organs, tissues, or eyes:
  • ____

    ____

    ____

    ____

    ____

• I authorize the use of my organs, tissues, or eyes:
  • For transplantation

    ____

    For therapy

    ____

    For research

    ____

    For medical education

    ____

    For any purpose authorized by law

    ____

    I understand that no vital organ, tissue, or eye may be removed for

    transplantation until after I have been pronounced dead under legal

    standards.

    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.

After any organ donation indicated in Part I, I wish my body to be donated

for use in a medical study program.

____

• 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.

    ____

    • ((or))

• This person:
  • Name:____

    Address:____

    ____

    ____

    Telephone Numbers:____

    (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:
  • ____

    ____

    ____

    ____

    ____

• 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 this donation 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 Number(s)

  ____

  ____

  (Signature of Witness)

  (Date)

  ____

  Telephone Number(s)