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Sample
Health Care Decision Making Forms (Maryland)
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Md. Ann.
Code, Health General § 5-603. Suggested forms - Living wills.
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Maryland Advance Directive:
Planning for Future Health Care Decisions
By: ______________________________________________________
Date of Birth:
______________________________________________________________________________
(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.
PART I: SELECTION 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)
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.
PART II: TREATMENT 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 your preference, initial one only. If you do not
want to state a preference here, cross through the whole section.)
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.
______________________________________________
| PART III: SIGNATURE
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 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.)
| (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.
| PART II: DONATION OF
BODY |
After any organ donation indicated
in Part I, I wish my body to be donated for use in a medical study program.
______________________________________________________
| PART III: DISPOSITION
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.
______________________________________________
((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:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
| PART IV: SIGNATURE
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 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)
Source:
Maryland State Law Library
(MSLL)
Last
Legal Update 02/07/08
(PLL/M.A.J.)
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