Health Care Decisions Guide - Jan 2013

MARYLANDADVANCEDIRECTIVE:

PLANNINGFORFUTUREHEALTHCAREDECISIONS

February2013

DearFellowMarylander:

Iampleasedtosendyouanadvancedirectiveformthatyoucanusetoplanforfuturehealthcaredecisions.Theformisoptional;youcanuseitifyouwantoruseothers,whicharejustasvalidlegally.Ifyouhaveanylegalquestionsaboutyourpersonalsituation,youshouldconsultyourownlawyer.Ifyoudecidetomakeanadvancedirective,besuretotalkaboutitwiththoseclosetoyou.Theconversationisjustasimportantasthedocument.Givecopiestofamilymembersorfriendsandyourdoctor.Alsomakesurethat,ifyougointoahospital,youbringacopy.Pleasedonotreturncompletedformstothisoffice.

Life‐threateningillnessisadifficultsubjecttodealwith.Ifyouplannow,however,yourchoicescanberespectedandyoucanrelieveatleastsomeoftheburdenfromyourlovedonesinthefuture.Youmayalsouseanotherenclosedformtomakeanorgandonationorplanforarrangementsafterdeath.

Hereissomerelated,importantinformation:

•IfyouwantinformationaboutDoNotResuscitate(DNR)Orders,pleasevisitthewebsite

•TheMarylandDepartmentofHealthandMentalHygienemakesavailableanadvancedirectivefocusedonpreferencesaboutmentalhealthtreatment.ThiscanbefoundontheInternetat:

Ihopethatthisinformationishelpfultoyou.Iregretthatoverwhelmingdemandlimitsustosupplyingonesetofformstoeachrequester.Butpleasefeelfreetomakeasmanycopiesasyouwish.AdditionalinformationaboutadvancedirectivescanbefoundontheInternetat:

DouglasF.GanslerAttorneyGeneral

-i-

HEALTHCAREPLANNINGUSINGADVANCEDIRECTIVES

OptionalFormIncluded

YourRightToDecide

Adultscandecideforthemselveswhethertheywantmedicaltreatment.Thisrighttodecide‐tosayyesornotoproposedtreatment‐appliestotreatmentsthatextendlife,likeabreathingmachineorafeedingtube.Tragically,accidentorillnesscantakeawayapersonʹsabilitytomakehealthcaredecisions.Butdecisionsstillhavetobemade.Ifyoucannotdoso,someoneelsewill.Thesedecisionsshouldreflectyourownvaluesandpriorities.

AMarylandlawcalledtheHealthCareDecisionsActsaysthatyoucandohealthcareplanningthrough“advancedirectives.”Anadvancedirectivecanbeusedtonameahealthcareagent.Thisissomeoneyoutrusttomakehealthcaredecisionsforyou.Anadvancedirectivecanalsobeusedtosaywhatyourpreferencesareabouttreatmentsthatmightbeusedtosustainyourlife.

TheStateoffersaformtodothisplanning,includedwiththispamphlet.Theformasawholeiscalled“MarylandAdvanceDirective:PlanningforFutureHealthCareDecisions.”Ithasthreepartstoit:PartI,SelectionofHealthCareAgent;PartII,TreatmentPreferences(“LivingWill”);andPartIII,SignatureandWitnesses.Thispamphletwillexplaineachpart.

Theadvancedirectiveismeanttoreflectyourpreferences.Youmaycompleteallofit,oronlypart,andyoumaychangethewording.Youarenotrequiredbylawtousetheseforms.Differentforms,writtenthewayyouwant,mayalsobeused.Forexample,onewidelypraisedform,calledFiveWishes,isavailable(forasmallfee)fromthenonprofitorganizationAgingWithDignity.YoucangetinformationaboutthatdocumentfromtheInternetat

-ii-

AgingwithDignity,P.O.Box1661,Tallahassee,FL32302.

Thisoptionalformcanbefilledoutwithoutgoingtoalawyer.Butifthereisanythingyoudonotunderstandaboutthelaworyourrights,youmightwanttotalkwithalawyer.Youcanalsoaskyourdoctortoexplainthemedicalissues,includingthepotentialbenefitsorriskstoyouofvariousoptions.Youshouldtellyourdoctorthatyoumadeanadvancedirectiveandgiveyourdoctoracopy,alongwithotherswhocouldbeinvolvedinmakingthesedecisionsforyouinthefuture.

InPartIIIoftheform,youneedtwowitnessestoyoursignature.Nearlyanyadultcanbeawitness.Ifyounameahealthcareagent,though,thatpersonmaynotbeawitness.Also,oneofthewitnessesmustbeapersonwhowouldnotfinanciallybenefitbyyourdeathorhandleyourestate.Youdonotneedtohavetheformnotarized.

Thispamphletalsocontainsaseparateformcalled“AfterMyDeath.”Liketheadvancedirective,usingitisoptional.Thisformhasfourpartstoit:PartI,OrganDonation;PartII,DonationofBody;PartIII,DispositionofBodyandFuneralArrangements;andPartIV,SignatureandWitnesses.

Onceyoumakeanadvancedirective,itremainsineffectunlessyourevokeit.Itdoesnotexpire,andneitheryourfamilynoranyoneexceptyoucanchangeit.Youshouldreviewwhatyouʹvedoneonceinawhile.Thingsmightchangeinyourlife,oryourattitudesmightchange.Youarefreetoamendorrevokeanadvancedirectiveatanytime,aslongasyoustillhavedecision‐makingcapacity.Tellyourdoctorandanyoneelsewhohasacopyofyouradvancedirectiveifyouamenditorrevokeit.

IfyoualreadyhaveapriorMarylandadvancedirective,livingwill,oradurablepowerofattorneyforhealthcare,thatdocumentisstillvalid.Also,ifyoumadeanadvancedirectiveinanotherstate,itisvalidinMaryland.Youmightwanttoreviewthesedocumentstoseeifyouprefertomakeanewadvancedirectiveinstead.

PartIoftheAdvanceDirective:SelectionofHealthCareAgent

Youcannameanyoneyouwant(except,ingeneral,someonewhoworksforahealthcarefacilitywhereyouarereceivingcare)tobeyourhealthcareagent.Tonameahealthcareagent,usePartIoftheadvancedirectiveform.(Somepeoplerefertothiskindofadvancedirectiveasa“durablepowerofattorneyforhealthcare.”)Youragentwillspeakforyouandmakedecisionsbasedonwhatyouwouldwantdoneoryourbestinterests.Youdecidehowmuchpoweryouragentwillhavetomakehealthcaredecisions.Youcanalsodecidewhenyouwantyouragenttohavethispower─rightaway,oronlyafteradoctorsaysthatyouarenotabletodecideforyourself.

Youcanpickafamilymemberasahealthcareagent,butyoudonʹthaveto.Remember,youragentwillhavethepowertomakeimportanttreatmentdecisions,evenifotherpeopleclosetoyoumighturgeadifferentdecision.Choosethepersonbestqualifiedtobeyourhealthcareagent.Also,considerpickingoneortwoback‐upagents,incaseyourfirstchoiceisn’tavailablewhenneeded.Besuretoinformyourchosenpersonandmakesurethatheorsheunderstandswhat’smostimportanttoyou.Whenthetimecomesfordecisions,yourhealthcareagentshouldfollowyourwrittendirections.

Wehaveahelpfulbookletthatyoucangivetoyourhealthcareagent.Itiscalled“MakingMedicalDecisionsforSomeoneElse:AMarylandHandbook.”YouoryouragentcangetacopyontheInternetbyvisitingtheAttorneyGeneral’shomepageat:

Youcanrequestacopybycalling410‐576‐7000.

Theformincludedwiththispamphletdoesnotgiveanyonepowertohandleyourmoney.Wedonothaveastandardformtosend.Talktoyourlawyeraboutplanningforfinancialissuesincaseofincapacity.

PartIIoftheAdvanceDirective:TreatmentPreferences (“LivingWill”)

Youhavetherighttouseanadvancedirectivetosaywhatyouwantaboutfuturelife‐sustainingtreatmentissues.YoucandothisinPartIIoftheform.Ifyoubothnameahealthcareagentandmakedecisionsabouttreatmentinanadvancedirective,it’simportantthatyousay(inPartII,paragraphG)whetheryouwantyouragenttobestrictlyboundbywhatevertreatmentdecisionsyoumake.

PartIIisalivingwill.Itletsyoudecideaboutlife‐sustainingproceduresinthreesituations:whendeathfromaterminalconditionisimminentdespitetheapplicationoflife‐sustainingprocedures;aconditionofpermanentunconsciousnesscalledapersistentvegetativestate;andend‐stagecondition,whichisanadvanced,progressive,andincurableconditionresultingincompletephysicaldependency.Oneexampleofend‐stageconditioncouldbeadvancedAlzheimerʹsdisease.

FREQUENTLYASKEDQUESTIONSABOUTADVANCEDIRECTIVESINMARYLAND

1.MustIuseanyparticularform?

No.Anoptionalformisprovided,butyoumaychangeitoruseadifferentformaltogether.Ofcourse,nohealthcareprovidermaydenyyoucaresimplybecauseyoudecidednottofilloutaform.

2.Whocanbepickedasahealthcareagent?

Anyonewhois18orolderexcept,ingeneral,anowner,operator,oremployeeofahealthcarefacilitywhereapatientisreceivingcare.

3.Whocanwitnessanadvancedirective?

Twowitnessesareneeded.Generally,anycompetentadultcanbeawitness,includingyourdoctororotherhealthcareprovider(butbeawarethatsomefacilitieshaveapolicyagainsttheiremployeesservingaswitnesses).Ifyounameahealthcareagent,thatpersoncannotbeawitnessforyouradvancedirective.Also,oneofthetwowitnessesmustbesomeonewho(i)willnotreceivemoneyorpropertyfromyourestateand(ii)isnottheoneyouhavenamedtohandleyourestateafteryourdeath.

4.Dotheformshavetobenotarized?

No,butifyoutravelfrequentlytoanotherstate,checkwithaknowledgeablelawyertoseeifthatstaterequiresnotarization.

5.Doanyofthesedocumentsdealwithfinancialmatters?

No.Ifyouwanttoplanforhowfinancialmatterscanbehandledifyoulosecapacity,talkwithyourlawyer.

6.Whenusingtheseformstomakeadecision,howdoIshowthechoicesthatIhavemade?

Writeyourinitialsnexttothestatementthatsayswhatyouwant.DonʹtusecheckmarksorXʹs.Ifyouwant,youcanalsodrawlinesalltheway

throughotherstatementsthatdonotsaywhatyouwant.

7.ShouldIfilloutbothPartsIandIIoftheadvancedirectiveform?

Itdependsonwhatyouwanttodo.Ifallyouwanttodoisnameahealthcareagent,justfilloutPartsIandIII,andtalktothepersonabouthowtheyshoulddecideissuesforyou.Ifallyouwanttodoisgivetreatmentinstructions,filloutPartsIIandIII.Ifyouwanttodoboth,filloutallthreeparts.

8.Aretheseformsvalidinanotherstate?

Itdependsonthelawoftheotherstate.Moststatelawsrecognizeadvancedirectivesmadesomewhereelse.

9.HowcanIgetadvancedirectiveformsforanotherstate?

ContactCaringConnections(NHPCO)at1‐800‐658‐8898orontheInternetat:

10.TowhomshouldIgivecopiesofmyadvancedirective?

Givecopiestoyourdoctor,yourhealthcareagentandbackupagent(s),hospitalornursinghomeifyouwillbestayingthere,andfamilymembersorfriendswhoshouldknowofyourwishes.Considercarryingacardinyourwalletsayingyouhaveanadvancedirectiveandwhotocontact.

11.Doesthefederallawonmedicalrecordsprivacy(HIPAA)requirespeciallanguageaboutmyhealthcareagent?

Speciallanguageisnotrequired,butitisprudent.LanguageaboutHIPAAhasbeenincorporatedintotheform.

12.CanmyhealthcareagentormyfamilydecidetreatmentissuesdifferentlyfromwhatIwrote?

Itdependsonhowmuchflexibilityyouwanttogive.Somepeoplewanttogivefamilymembersorothersflexibilityinapplyingthelivingwill.Otherpeoplewantitfollowedverystrictly.SaywhatyouwantinPartII,ParagraphG.

13.

Isanadvancedirectivethe

sameasa

18.

Whataboutdonatingmybodyformedical

“Patient’sPlanofCare”,“Instructionson

educationorresearch?

Current

Life‐Sustaining

Treatment

Options”form,orMedicalOrdersforLife‐

PartIIofthe“After

MyDeath”

formisa

SustainingTreatment(MOLST)form?

generalstatementofthesewishes.

TheState

AnatomyBoardhasa

specific

donation

No.Theseareformsusedin

healthcare

program,withapre‐registrationformavailable.

facilitiestodocumentdiscussionsaboutcurrent

CalltheAnatomyBoard

at1‐800‐879‐2728for

life‐sustainingtreatmentisues.Theseformsare

notmeantforuseasanyone’sadvancedirective.

thatformandadditionalinformation.

Instead,theyaremedicalrecords,

tobedone

19.IfIappointahealth

careagentandthe

only

whena

doctororother

healthcare

agentandanyback‐upagent

professionalpresentsanddiscussestheissues.A

diesorotherwisebecomesunavailable,a

MOLSTformcontainsmedicalordersregarding

surrogatedecisionmakermay

needtobe

life‐sustainingtreatments

relatingto

apatient’s

consulted

tomake

thesame

treatment

medicalcondition.

decisionsthatmyhealthcareagentwould

havemade.

Isthesurrogatedecisionmaker

14.

Canmydoctoroverridemylivingwill?

requiredtofollowmyinstructionsgivenin

theadvancedirective?

Usually,

no.However,adoctorisnot

requiredtoprovidea“medically

ineffective”

Yes,the

surrogate

decision

makeris

treatmentevenifalivingwillasksforit.

requiredtomaketreatmentdecisionsbasedon

yourknownwishes.Anadvancedirectivethat

15.

IfIhave

anadvancedirective,doIalso

containsclear

andunambiguousinstructions

needaMOLSTform?

regardingtreatmentoptionsisthebestevidence

ofyourknown

wishesandthereforemustbe

Yes.The

MOLSTformcontainsmedical

honoredbythesurrogatedecisionmaker.

ordersthatwillhelpensurethatallhealthcare

providersareawareofyourwishes.Ifyoudonʹt

PartII,paragraphGenablesyoutochoose

want

emergencymedical

servicespersonnelto

oneoftwooptionswithregardtothedegreeof

trytoresuscitateyouintheeventofcardiacor

flexibilityyouwishtograntthepersonwhowill

respiratoryarrest,youmusthaveaMOLSTform

ultimatelymake

treatmentdecisionsforyou,

containingaDNRordersignedbyyourdoctor

whetherthatpersonisahealthcareagentora

ornursepractitioneroravalidEMS/DNRform.

surrogatedecisionmaker.

Underthefirstoption

youwouldinstructthedecisionmakerthatyour

16.

Doesthe

DNROrderhave

tobeina

stated

preferencesaremeantto

guidethe

particularform?

decisionmakerbutmaybedepartedfromifthe

decisionmakerbelievesthatdoingsowouldbe

Yes.Emergencymedicalservicespersonnl

inyourbestinterests.

Thesecondoption

haveverylittletimetoevaluatethesituationand

actappropriately.So,itisnotpracticaltoask

requiresthedecisionmakertofollowyourstated

preferencesstrictly,evenifthedecisionmaker

them

form

tointerpretdocumentsthatmayvaryin

andcontent.Instead,thestandardized

thinkssomealternativewouldbebetter.

MOLSTform

hasbeendeveloped.

Haveyour

REVISEDJANUARY2013

doctororhealthcarefacilityvisit

theMOLST

web

siteat

IFYOUHAVEOTHERQUESTIONS,PLEASE

TALKTOYOUR

the

Maryland

InstituteforEmergencyMedical

DOCTORORYOURLAWYER.

R,IFYOUHAVEAQUESION

ServicesSystemat(410)706‐4367

informationontheMOLSTform.

toobtain

ABOUTTHEFORMSTHATISNOTANSWEREDINTHISPAMP

LET,

YOU

CANCALL

THEHEALTH

POLICY

IVISIONOF

THE

17.

CanIfilldonor?

outaformtobecomeanorgan

ATTORNEYGENERAL’SOFFICEAT(410)767‐6918ORE‐MAILUS

AT.

Yes,Use

PartIofthe“After

MyDeath”

MOEINFORMATIONABOUT

ADVANCEDIRECTIVESCABE

form.

OBTAINEDFROM

URWEBSITET:

htm

ealthpol/AdvanceDirectives.

ARYLAN

ADVAN

EDIRECTIVE:

PLANNINGFORFU

UREHEALTHCAREDECISIONS

By:

(PrintName)

DateofBirth:

(Month/Day/Year)

Usingthisadvancedirectiveformtodohealthcareplanningiscompletelyoptional.OtherformsarealsovalidinMaryland.Nomatterwhatformyouuse,talktoyourfamilyandothersclosetoyouaboutyourwishes.

Thisformhastwopartstostateyourwishes,andathirdpartforneededsignatures.PartIofthisformletsyouanswerthisquestion:Ifyoucannot(ordonot

wantto

makeyourownhealthcaredecisions,whodoyouwanttomakethemforyou?

Thepersonyoupickiscalledyourhealthcareagent.Makesureyoutalktoyourhealth

careagent(andanyback‐upagents)aboutthisimportantrole.PartIIletsyouwrite

yourpreferencesabouteffortstoextendyourlifeinthreesituations:terminalcondition,

persistentvegetativestate,andend‐stagecondition.Inadditiontoyourhealthcare

planningdecisions,youcanchoosetobecomeanorgandonorafteryourdeathby

fillingouttheformforthattoo.

➔YoucanfilloutPartsIandIIofthisform,oronlyPartI,oronlyPartII.Usetheformtoreflectyourwishes,thensigninfrontoftwowitnesses(PartIII).Ifyourwishes

change,makeanewadvancedirective.»

Makesureyougiveacopyofthecompletedformtoyourhealthcareagent,yourdoctor,andotherswhomightneedit.Keepacopyathomeinaplacewheresomeone

cangetitifneeded.Reviewwhatyouhavewritten

periodically.

PARTI:SELECTIOOFHEALTHCAREAENT

A.SelectionofPrimaryAgent

Iselectthefollowingindividualasmyagenttomakehealthcaredecisionsforme:Name: Address:

TelephoneNumbers:

(homeandcell)

B.SelectionofBack‐upAgents

(Optional;formvalidifleftblank)

1.Ifmyprimaryagentcannotbecontactedintimeorforanyreasonisunavailableorunableorunwillingtoactasmyagent,thenIselectthefollowingpersontoactinthiscapacity:

Name:

Address:

TelephoneNumbers:

(homeandcell)

2.Ifmyprimaryagentandmyfirstback‐upagentcannotbecontactedintimeorforanyreasonareunavailableorunableorunwillingtoactasmyagent,thenIselectthefollowingpersontoactinthiscapacity:

Name:

Address:

TelephoneNumbers:

(homeandcell)

C.PowersandRightsofHealthCareAgent

Iwantmyagenttohavefullpowertomakehealthcaredecisionsforme,includingthepowerto:

1.Consentornottomedicalproceduresandtreatmentswhichmydoctorsoffer,includingthingsthatareintendedtokeepmealive,likeventilatorsandfeedingtubes;

2.Decidewhomydoctorandotherhealthcareprovidersshouldbe;and

3.DecidewhereIshouldbetreated,includingwhetherIshouldbeinahospital,nursinghome,othermedicalcarefacility,orhospiceprogram.

4.Ialsowantmyagentto:

a.RidewithmeinanambulanceifeverIneedtoberushedtothehospital;and

b.BeabletovisitmeifIaminahospitaloranyotherhealthcarefacility.

THISADVANCEDIRECTIVEDOESNOTMAKEMYAGENTRESPONSIBLEFORANYOFTHECOSTSOFMYCARE.

Thispowerissubjecttothefollowingconditionsorlimitations:(Optional;formvalidifleftblank)

D.HowmyAgentistoDecideSpecificIssues

Itrustmyagent’sjudgment.Myagentshouldlookfirsttoseeifthereisanythingin PartIIofthisadvancedirectivethathelpsdecidetheissue.Then,myagentshouldthinkabouttheconversationswehavehad,myreligiousandotherbeliefsandvalues,mypersonality,andhowIhandledmedicalandotherimportantissuesinthepast.IfwhatIwoulddecideisstillunclear,thenmyagentistomakedecisionsformethatmyagentbelievesareinmybestinterest.Indoingso,myagentshouldconsiderthebenefits,burdens,andrisksofthechoicespresentedbymydoctors.

E.PeopleMyAgentShouldConsult

(Optional;formvalidifleftblank)

Inmakingimportantdecisionsonmybehalf,Iencouragemyagenttoconsultwiththefollowingpeople.Byfillingthisin,Idonotintendtolimitthenumberofpeoplewithwhommyagentmightwanttoconsultormyagent’spowertomakedecisions.

Name(s)TelephoneNumber(s):

F.InCaseofPregnancy

(Optional,forwomenofchild‐bearingyearsonly;formvalidifleftblank)

IfIampregnant,myagentshallfollowthesespecificinstructions:

G.AccesstomyHealthInformation–FederalPrivacyLaw(HIPAA)Authorization

1.If,priortothetimethepersonselectedasmyagenthaspowertoactunderthisdocument,mydoctorwantstodiscusswiththatpersonmycapacitytomakemyownhealthcaredecisions,Iauthorizemydoctortodiscloseprotectedhealthinformationwhichrelatestothatissue.

2.Oncemyagenthasfullpowertoactunderthisdocument,myagentmayrequest,receive,andreviewanyinformation,oralorwritten,regardingmyphysicalormentalhealth,including,butnotlimitedto,medicalandhospitalrecordsandotherprotectedhealthinformation,andconsenttodisclosureofthisinformation.

3.Forallpurposesrelatedtothisdocument,myagentismypersonalrepresentativeundertheHealthInsurancePortabilityandAccountabilityAct(HIPAA).Myagentmaysign,asmypersonalrepresentative,anyreleaseformsorotherHIPAA‐relatedmaterials.

H.EffectivenessofthisPart

(Readbothofthesestatementscarefully.Then,initialoneonly.)

Myagent’spowerisineffect:

1.ImmediatelyafterIsignthisdocument,subjecttomyrighttomakeanydecisionaboutmyhealthcareifIwantandamableto.

✎

>OR<

2.WheneverIamnotabletomakeinformeddecisionsaboutmyhealthcare,eitherbecausethedoctorinchargeofmycare(attendingphysician)decidesthatIhavelostthisabilitytemporarily,ormyattendingphysicianandaconsultingdoctoragreethatIhavelostthisabilitypermanently.

✎

Iftheonlythingyouwanttodoisselectahealthcareagent,skipPartII.GotoPartIIItosignandhavetheadvancedirectivewitnessed.Ifyoualsowanttowriteyourtreatmentpreferences,gotoPartII.Alsoconsiderbecominganorgandonor,usingtheseparateformforthat.

PARTII:TREATMENTPREFERENCES(“LIVINGWILL”)

A.StatementofGoalsandValues

(Optional:Formvalidifleftblank)

Iwanttosaysomethingaboutmygoalsandvalues,andespeciallywhat’smostimportanttomeduringthelastpartofmylife:

B.PreferenceinCaseofTerminalCondition

(Ifyouwanttostatewhatyourpreferenceis,initialoneonly.Ifyoudonotwanttostate

apreferencehere,crossthroughthewholesection.)

Ifmydoctorscertifythatmydeathfromaterminalconditionisimminent,eveniflife‐sustainingproceduresareused:

1.Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

>OR<

2.Keepmecomfortableandallownaturaldeathtooccur.Idonotwantmedicalinterventionsusedtotrytoextendmylife.IfIamunabletotakeenoughnourishmentbymouth,however,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

>OR<

3.Trytoextendmylifeforaslongaspossible,usingallavailableinterventionsthatinreasonablemedicaljudgmentwouldpreventordelaymydeath.IfIamunabletotakeenoughnourishmentbymouth,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

C.PreferenceinCaseofPersistentVegetativeState

(Ifyouwanttostatewhatyourpreferenceis,initialoneonly.Ifyoudonotwanttostate

apreferencehere,crossthroughthewholesection.)

IfmydoctorscertifythatIaminapersistentvegetativestate,thatis,ifIamnotconsciousandamnotawareofmyselformyenvironmentorabletointeractwithothers,andthereisnoreasonableexpectationthatIwilleverregainconsciousness:

1.Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

>OR<

✎

>OR<

✎

D.PreferenceinCaseofEnd‐StageCondition

(Ifyouwanttostatewhatyourpreferenceis,initialoneonly.Ifyoudonotwanttostate

apreferencehere,crossthroughthewholesection.)

IfmydoctorscertifythatIaminanend‐statecondition,thatis,anincurableconditionthatwillcontinueinitscourseuntildeathandthathasalreadyresultedinlossofcapacityandcompletephysicaldependency:

1.Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

>OR<

✎

>OR<

✎

E.PainRelief

Nomatterwhatmycondition,givemethemedicineorothertreatmentIneedtorelievepain.

F.InCaseofPregnancy

(Optional,forwomenofchild‐bearingyearsonly;formvalidifleftblank)

IfIampregnant,mydecisionconcerninglife‐sustainingproceduresshallbemodifiedasfollows:

G.EffectofStatedPreferences

(Readbothofthesestatementscarefully.Then,initialoneonly.)

1.IrealizeIcannotforeseeeverythingthatmighthappenafterIcannolongerdecideformyself.Mystatedpreferencesaremeanttoguidewhoeverismakingdecisionsonmybehalfandmyhealthcareproviders,butIauthorizethemtobeflexibleinapplyingthesestatementsiftheyfeelthatdoingsowouldbeinmybestinterest.

✎

>OR

2.IrealizeIcannotforeseeeverythingthatmighthappenafterIcannolongerdecideformyself.Still,Iwantwhoeverismakingdecisionsonmybehalfandmyhealthcareproviderstofollowmystatedpreferencesexactlyaswritten,eveniftheythinkthatsomealternativeisbetter.

✎

PARTIII:SIGNATUREANDWITNESSES

BysigningbelowastheDeclarant,IindicatethatIamemotionallyandmentallycompetenttomakethisadvancedirectiveandthatIunderstanditspurposeandeffect.IalsounderstandthatthisdocumentreplacesanysimilaradvancedirectiveImayhavecompletedbeforethisdate.

(SignatureofDeclarant)(Date)

TheDeclarantsignedoracknowledgedsigningthisdocumentinmypresenceand,baseduponpersonalobservation,appearstobeemotionallyandmentallycompetenttomakethisadvancedirective.

(SignatureofWitness)(Date)

TelephoneNumber(s):

(SignatureofWitness)(Date)

TelephoneNumber(s):

(Note:AnyoneselectedasahealthcareagentinPartImaynotbeawitness.Also,atleastoneofthewitnessesmustbesomeonewhowillnotknowinglyinheritanythingfromtheDeclarantorotherwiseknowinglygainafinancialbenefitfromtheDeclarant’sdeath.Marylandlawdoesnotrequirethisdocumenttobenotarized.)

AFTERMYDEATH

(Thisdocumentisoptional.Doonlywhatreflectsyourwishes.)

By:DateofBirth:

(PrintName)(Month/Day/Year)

PARTI:ORGANDONATION

(Initialtheonesthatyouwant.Crossthroughanythatyoudonotwant.)

UponmydeathIwishtodonate:✎

Anyneededorgans,tissues,oreyes.✎

Onlythefollowingorgans,tissuesoreyes:

Iauthorizetheuseofmyorgans,tissues,oreyes:

Fortransplantation✎

Fortherapy✎

Forresearch✎

Formedicaleducation✎

Foranypurposeauthorizedbylaw✎

Iunderstandthatnovitalorgan,tissue,oreyemayberemovedfortransplantationuntilafterIhavebeenpronounceddead.ThisdocumentisnotintendedtochangeanythingaboutmyhealthcarewhileIamstillalive.Afterdeath,Iauthorizeanyappropriatesupportmeasurestomaintaintheviabilityfortransplantationofmyorgans,tissues,andeyesuntilorgan,tissue,andeyerecoveryhasbeencompleted.Iunderstandthatmyestatewillnotbechargedforanycostsrelatedtothisdonation.

PARTII:DONATIONOFBODY

AfteranyorgandonationindicatedinPartI,Iwishmybodytobedonatedforuseinamedicalstudyprogram.

✎

PARTIII:DISPOSITIONOFBODYANDFUNERALARRANGEMENTS

Iwantthefollowingpersontomakedecisionsaboutthedispositionofmybodyandmyfuneralarrangements:(Eitherinitialthefirstorfillinthesecond.)

ThehealthcareagentwhoInamedinmyadvancedirective.

>OR<

Thisperson:Name:Address:

TelephoneNumber(s):

✎

(HomeandCell)

IfIhavewrittenmywishesbelow,theyshouldbefollowed.Ifnot,thepersonIhavenamedshoulddecidebasedonconversationswehavehad,myreligiousorotherbeliefsandvalues,mypersonality,andhowIreactedtootherpeoples’funeralarrangements.Mywishesaboutthedispositionofmybodyandmyfuneralarrangementsare:

PARTIV:SIGNATUREANDWITNESSES

Bysigningbelow,IindicatethatIamemotionallyandmentallycompetenttomakethisdonationandthatIunderstandthepurposeandeffectofthisdocument.

(SignatureofDonor)(Date)

TheDonorsignedoracknowledgedsigningtheforegoingdocumentinmypresenceand,baseduponpersonalobservation,appearstobeemotionallyandmentallycompetenttomakethisdonation.

(SignatureofWitness)(Date)

TelephoneNumber(s):

(SignatureofWitness)(Date)

TelephoneNumber(s):

AFTE

artII:D

MYDEATH

nationofBody

The

StateAnatomyBoard,aunit

oftheD

partmentof

HealthandMe

talHygieneadmini

tersastatewideBody

DonationProgram.

natomicalDonationallows

individualstodedicatetheuseoftheirbodiesupondeth

toadvancemedicaleducation,clinicaland

allied-health

traini

gandresearchstudytoMaryland’smedicalstudy

institutions.T

eAnato

yBoard

requiresindividualsto

pre-r

gisterpriortodeat

asana

atomicaldonortothe

state

BodyDonationProgram.

hereare

nomedical

restrictions or

qualifications to becoming

an a “Body

Donor”. AtdeaththeBoardwillassumethecustodyand

controlofthebodyforstudyuse.

Itistrulyalegacyleft

behindforotherstohavehealthierlives.

ordonation

infor

ationandformsyoucancontacttheBoardtoll-free

at1-800.879.2728

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