Maryland Advance Health Care Directive(Living Will)

MARYLANDADVANCEDIRECTIVE:PLANNINGFORFUTUREHEALTHCAREDECISIONS

By:DateofBirth:

(PrintName)(Month/Day/Year)

Usingthisadvancedirectiveformtodohealthcareplanningiscompletelyoptional.OtherformsarealsovalidinMaryland.Nomatterwhatformyouuse,talktoyourfamilyandothersclosetoyouaboutyourwishes.

Thisformhastwopartstostateyourwishes,andathirdpartforneededsignatures.PartIofthisformletsyouanswerthisquestion:Ifyoucannot(ordonotwantto)makeyourownhealthcaredecisions,whodoyouwanttomakethemforyou?Thepersonyoupickiscalledyourhealthcareagent.Makesureyoutalktoyourhealthcareagent(andanyback-upagents)aboutthisimportantrole.PartIIletsyouwriteyourpreferencesabouteffortstoextendyourlifeinthreesituations:terminalcondition,persistentvegetativestate,andend-stagecondition.Inadditiontoyourhealthcareplanning

decisions,youcanchoosetobecomeanorgandonorafteryourdeathbyfillingouttheformforthattoo.

➔YoucanfilloutPartsIandIIofthisform,oronlyPartI,oronlyPartII.Usetheformtoreflectyourwishes,thensigninfrontoftwowitnesses(PartIII).Ifyourwisheschange,makeanewadvancedirective.

Makesureyougiveacopyofthecompletedformtoyourhealthcareagent,yourdoctor,andotherswhomightneedit.Keepacopyathomeinaplacewheresomeonecangetitifneeded.Reviewwhatyouhavewrittenperiodically.

PARTI:SELECTIONOFHEALTHCAREAGENT

A. SelectionofPrimaryAgent

Iselectthefollowingindividualasmyagenttomakehealthcaredecisionsforme:

Name: Address:

TelephoneNumbers:

(homeandcell)

B.SelectionofBack-upAgents

(Optional;formvalidifleftblank)

1. Ifmyprimaryagentcannotbecontactedintimeorforanyreasonisunavailableorunableorunwillingtoactasmyagent,thenIselectthefollowingpersontoactinthiscapacity:

Name: Address:

TelephoneNumbers:

(homeandcell)

2. Ifmyprimaryagentandmyfirstback-upagentcannotbecontactedintimeorforanyreasonareunavailableorunableorunwillingtoactasmyagent,thenIselectthefollowingpersontoactinthiscapacity:

Name:

TelephoneNumbers:

(homeandcell)

C. PowersandRightsofHealthCareAgent

Iwantmyagenttohavefullpowertomakehealthcaredecisionsforme,includingthepowerto:

1. Consentornottomedicalproceduresandtreatmentswhichmydoctorsoffer,includingthingsthatareintendedtokeepmealive,likeventilatorsandfeedingtubes;

2. Decidewhomydoctorandotherhealthcareprovidersshouldbe;and

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

4. Ialsowantmyagentto:

a. RidewithmeinanambulanceifeverIneedtoberushedtothehospital;andb. BeabletovisitmeifIaminahospitaloranyotherhealthcarefacility.

THISADVANCEDIRECTIVEDOESNOTMAKEMYAGENTRESPONSIBLEFORANYOFTHECOSTSOFMYCARE.

Thispowerissubjecttothefollowingconditionsorlimitations:(Optional;formvalidifleftblank)

D. HowmyAgentistoDecideSpecificIssues

Itrustmyagent’sjudgment.MyagentshouldlookfirsttoseeifthereisanythinginPartIIofthisadvancedirectivethathelpsdecidetheissue.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,

skip Part II. Go to Part III to sign and have the advance

directivewitnessed.Ifyoualsowanttowriteyourtreatmentpreferences,gotoPartII.Alsoconsiderbecominganorgandonor,usingtheseparateformforthat.

PARTII:TREATMENTPREFERENCES(“LIVINGWILL”)

A.StatementofGoalsandValues

(Optional:Formvalidifleftblank)

Iwanttosaysomethingaboutmygoalsandvalues,andespeciallywhat’smostimportanttomeduringthelastpartofmylife:

B. PreferenceinCaseofTerminalCondition

(Ifyouwanttostatewhatyourpreferenceis,initial oneonly.Ifyoudonotwanttostatea

preferencehere,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.Ifyoudonotwanttostatea

preferencehere,crossthroughthewholesection.)

IfmydoctorscertifythatIaminapersistentvegetativestate,thatis,ifIamnotconsciousandamnotawareofmyselformyenvironmentorabletointeractwithothers,andthereisnoreasonableexpectationthatIwilleverregainconsciousness:

1.Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

OR<

✎_

✎

D. PreferenceinCaseofEnd-StageCondition

(Ifyouwanttostatewhatyourpreferenceis,initialoneonly.Ifyoudonotwanttostateapreferencehere,crossthroughthewholesection.)

IfmydoctorscertifythatIaminanend-statecondition,thatis,anincurableconditionthatwillcontinueinitscourseuntildeathandthathasalreadyresultedinlossofcapacityandcompletephysicaldependency:

1.Keepmecomfortableandallownaturaldeathtooccur.Idonotwantanymedicalinterventionsusedtotrytoextendmylife.Idonotwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

OR<

✎

OR<

3. Trytoextendmylifeforaslongaspossible,usingallavailableinterventionsthatinreasonablemedicaljudgmentwouldpreventordelaymydeath.IfIamunabletotakeenoughnourishmentbymouth,Iwanttoreceivenutritionandfluidsbytubeorothermedicalmeans.

✎

E. PainRelief

Nomatterwhatmycondition,givemethemedicineorothertreatmentIneedtorelievepain.

F. InCaseofPregnancy

(Optional,forwomenofchild-bearingyearsonly;formvalidifleftblank)

IfIampregnant,mydecisionconcerninglife-sustainingproceduresshallbemodifiedasfollows:

G. EffectofStatedPreferences

(Readbothofthesestatementscarefully.Then,initialoneonly.)

1.IrealizeIcannotforeseeeverythingthatmighthappenafterIcannolongerdecideformyself.Mystatedpreferencesaremeanttoguidewhoeverismakingdecisionsonmybehalfandmyhealthcareproviders,butIauthorizethemtobeflexibleinapplyingthesestatementsiftheyfeelthatdoingsowouldbeinmybestinterest.

✎

2.IrealizeIcannotforeseeeverythingthatmighthappenafterIcannolongerdecideformyself.Still,Iwantwhoeverismakingdecisionsonmybehalfandmyhealthcareproviderstofollowmystatedpreferencesexactlyaswritten,eveniftheythinkthatsomealternativeisbetter.

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PARTIII:SIGNATUREANDWITNESSES

BysigningbelowastheDeclarant,IindicatethatIamemotionallyandmentallycompetenttomakethisadvancedirectiveandthatIunderstanditspurposeandeffect.IalsounderstandthatthisdocumentreplacesanysimilaradvancedirectiveImayhavecompletedbeforethisdate.

(SignatureofDeclarant)(Date)

TheDeclarantsignedoracknowledgedsigningthisdocumentinmypresenceand,baseduponpersonalobservation,appearstobeemotionallyandmentallycompetenttomakethisadvancedirective.

(SignatureofWitness)(Date)TelephoneNumber(s):

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

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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,oreye mayberemovedfortransplantationuntilafterIhavebeenpronounceddead. ThisdocumentisnotintendedtochangeanythingaboutmyhealthcarewhileIamstillalive. Afterdeath,Iauthorizeanyappropriatesupportmeasurestomaintaintheviabilityfortransplantationofmyorgans,tissues,andeyesuntilorgan,tissue,andeyerecoveryhasbeencompleted.Iunderstandthatmyestatewillnotbechargedforanycostsrelatedtothisdonation.

PARTII:DONATIONOFBODY

AfteranyorgandonationindicatedinPartI,Iwishmybodytobedonatedforuseinamedicalstudyprogram.

✎

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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):

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