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Maryland : ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ -6- ___ Address: ______________________________________ Phone: _______________________________________ Date: ________________ _____________________________________________ (Witness Signature) Print Namein my presence and based upon personal observation appears to be a competent individual. _____________________________________________ (Witness Signature) Print Name: ________________________________larant) (At least one of your witnesses may not be a person who may financially benefit by reason of Declarant's death). The declarant signed or acknowledged signing the foregoing advance directive y competent to make this advance directive and that I understand the purpose and effect of this document. ______________________ (Date) ____________________________________________ (Signature of Dec_____________________________________________________ _____________________________________________________________________________ -5- By signing below, I indicate that I am emotionally and mentalllowing space, indicate any other instructions regarding receipt or nonreceipt of any health care) _____________________________________________________________________________ ________________________d that my estate will not be charged for any costs associated with my decision to donate my organs, tissues, or eyes or the actual disposition of my organs, tissues, or eyes. (8) I direct (in the folth, I direct that all support measures be continued to maintain the viability for transplantation of my organs, tissues, and eyes until organ, tissue, and eye recovery has been completed. I understan_____ For medical education _____ For any purpose authorized by law. I understand that before any vital organ, tissue, or eye may be removed for transplantation, I must be pronounced dead. After dear eyes: _______________ ________________________________________________________ I authorize the use of my organs, tissues, or eyes: _____ For transplantation _____ For therapy _____ For research ____________________________________________________________________ -4- (7) Upon my death, I wish to donate: _____ Any needed organs, tissues, or eyes. _____ Only the following organs, tissues, oures shall be modified as follows: _____________________________________________________________________________ _____________________________________________________________________________ _________ect that no matter what my condition, I be given all available medical treatment in accordance with accepted health care standards. (6) If I am pregnant, my decision concerning life-sustaining procedive nutrition and hydration artificially. (4) I direct that no matter what my condition, medication not be given to me to relieve pain and suffering, if it would shorten my remaining life. (5) I dirdministration of nutrition and hydration artificially. __________ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to recee degree of medical certainty, treatment of the irreversible condition would be medically ineffective - __________ I direct that my life not be extended by life-sustaining procedures, including the a caused by injury, disease, or illness, as a result of which I have suffered severe and permanent deterioration indicated by incompetency and complete physical dependency and for which, to a reasonablnded by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially. (3) If I have an end-stage condition, that is a conditiony - __________ I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially. __________ I direct that my life not be exte- (2) If I am in a persistent vegetative state, that is, if I am not conscious and am not aware of my environment or able to interact with others, and there is no reasonable expectation of my recoverficially. __________ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially. -3e used there is no reasonable expectation of my recovery - __________ I direct that my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artit my health care providers to follow my instructions as set forth below. (Initial all those that apply.) (1) If my death from a terminal condition is imminent and even if life-sustaining procedures artial those statements you want to be included in the document and cross through those statements that do not apply.) If I am incapable of making an informed decision regarding my health care, I direcrt B Advance Medical Directive Health Care Instructions (Optional Form) (Cross through if you do not want to complete this portion of the form. If you do want to complete this portion of the form, ini_________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ Pant Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ ____________________________________his appointment of a health care agent in my presence and based upon my personal observation appears to be a competent individual. _____________________________________________ (Witness Signature) Priand that I understand its purpose and effect. ______________________ (Date) ____________________________________________ (Signature of Declarant) -2- The declarant signed or acknowledged signing thall not be liable for the costs of care based solely on this authorization. By signing below, I indicate that I am emotionally and mentally competent to make this appointment of a health care agent nsidering the benefits, burdens, and risks that might result from a given treatment or course of treatment, or from the withholding or withdrawal of a treatment or course of treatment. (6) My agent s wishes as otherwise known to my agent. If my wishes are unknown or unclear, my agent is to make health care decisions for me in accordance with my best interest, to be determined by my agent after coon regarding my health care; or ___________ When this document is signed. (5) My agent is to make health care decisions for me based on the health care instructions I give in this document and on my(4) My agent's authority becomes operative (initial the option that applies): ___________ When my attending physician and a second physician determine that I am incapable of making an informed decisi__________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ ng, in appropriate circumstances, life-sustaining procedures. (3) The authority of my agent is subject to the following provisions and limitations (or write none): ___________________________________transfer to another facility) any hospital, hospice, nursing home, adult home, or other medical care facility; and -1- d. Consent to the provision, withholding, or withdrawal of health care, includiot limited to, medical and hospital records, and consent to disclosure of this information; b. Employ and discharge my health care providers; c. Authorize my admission to or discharge from (including r and authority to make health care decisions for me, including the power to: a. Request, receive, and review any information, oral or written, regarding my physical or mental health, including, but n____________________________________________________ _____________________________________________________________________________ (Full Name, Address, and Telephone Number) (2) My agent has full powedress, and Telephone Number) Optional: If this agent is unavailable or is unable or unwilling to act as my agent, then I appoint the following person to act in this capacity _________________________health care decisions for me: _____________________________________________________________________________ _____________________________________________________________________________ (Full Name, Ad_______________________________________________________, residing at _____________________________________________________________________________ appoint the following individual as my agent to make an agent, cross through any items in the form that you do not want to apply. If you decide to select a health care agent that person may not be a witness to your advance directive.) (1) I, _________ Advance Directive Part A Appointment of Health Care Agent (optional) (Cross through if you do not want to appoint a health care agent to make health care decisions for you. If you do want to appointences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject to the Disclaimers and Terms of Use found at findlegalforms.com. -6-hout consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommended when dealing with estate planning matters. Any possible tax consequnded and are not a substitute for legal and/or tax advice. Laws vary from time to time and from state to state. These forms should only be a starting point for you and should not be used or signed wited "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or as to their legal effect or completeness. [_]These forms are not inteord. (c) It shall be the responsibility of the declarant, to the extent reasonably possible, to notify any person to whom the declarant has provided a copy of the directive. [_] These forms are provide directive by an oral statement to a health care practitioner, the practitioner and a witness to the oral revocation shall document the substance of the oral revocation in the declarant's medical recigned and dated writing, by physical cancellation or destruction, by an oral statement to a health care practitioner or by the execution of a subsequent directive. (b) If a declarant revokes an advancservices provided to the declarant. A statement of medications preferred by the declarant for psychiatric treatment; § 5-604. (a) An advance directive may be revoked at any time by a declarant by a st the declarant would prefer to provide mental health services; (3) and (4) Instruction regarding the notification of third parties and the release of information to third parties about mental health services may include: (1) declarant; The designation of an agent to make mental health services decisions for the (2) The identification of mental health professionals, programs, and facilities tha under § 5-604 of this subtitle for the revocation of an advance directive shall apply to the revocation of an advance directive for mental health services. (d) An advance directive for mental health ) An individual making an advance directive for mental health services shall follow the procedures for making an advance directive provided under § 5-602 of this subtitle. (2) The procedur es providedhealth services which may be provided to the individual if the individual becomes incompetent and has a need for mental health services either during, or as a result of, the incompetency. -5- (c) (1 5-602.1. (a) In this section, "mental health services" has the meaning stated in § 4-301(i)(1) of this article. (b) An individual who is competent may make an advance directive to outline the mental nce with the provisions of § 5-605(c) of this subtitle. (i) The absence of an advance directive creates no presumption as to the patient's intent to consent to or refuse life-sustaining procedures. §e agent that the agent has been named in an advance directive to act on the declarant's behalf. (h) Unless otherwise provided in the patient's advance directive, a patient's agent shall act in accordag the date the advance directive was made and the name of the attending physician, a part of the declarant's medical records. (g) It shall be the responsibility of the declarant to notify a health carake the advance directive or a copy of the advance directive a part of the declarant's medical records; or (ii) If the advance directive is oral, make the substance of the advance directive, includ in the physician of the existence of an advance directive. (2) An attending physician who is notified of the existence of the advance directive shall promptly: (i) If the advance directive is written, mo notify the attending physician that an advance directive has been made. In the event the declarant becomes comatose, incompetent, or otherwise incapable of communication, any other person may notifyscious, or unable to communicate by any means, the certification of a second physician is not required under paragraph (1) of this subsection. (f) (1) It shall be the responsibility of the declarant tective shall become effective when the declarant's attending physician and a second physician certify in writing that the patient is incapable of making an informed decision. (2) If a patient is unconed as part of the individual's medical record. The documentation shall be dated and signed by the attending physician and the witness. (e) (1) Unless otherwise provided in the document, an advance dirce directive shall have the same effect as a written advance directive if made in the presence of the attending physician and one witness and if the substance of the oral advance directive is documentance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure or to appoint an agent to make health care decisions for the individual. -4- (2) An oral advangly entitled to any portion of the estate of the declarant or knowingly entitled to any financial benefit by reason of the death of the declarant. (d) (1) Any competent individual may make an oral advn caring for the declarant if acting in good faith. (ii) The health care agent of the declarant may not serve as a witness. (iii) At least one of the witnesses must be an individual who is not knowin) (i) Except as provided in items (ii) and (iii) of this paragraph, any competent individual may serve as a witness to an advance directive, including an employee of a health care facility or physicia subtitle to make health care decisions for a declarant. (c) (1) A written advance directive shall be dated, signed by or at the express direction of the declarant, and subscribed by two witnesses. (2ld qualify as a surrogate decision maker under § 5-605(a) of this subtitle. (3) An agent appointed under this subtitle has decision making priority over any individuals otherwise authorized under thisted in the advance directive. (2) An owner, operator, or employee of a health care facility from which the declarant is receiving health care may not serve as a health care agent unless the person wouom that individual. (b) (1) Any competent individual may, at any time, make a written advance directive appointing an agent to make health care decisions for the individual under the circumstances sta § 5-602. (a) Any competent individual may, at any time, make a written advance directive regarding the provision of health care to that individual, or the withholding or withdrawal of health care frby injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and from which, despite the application of life-sustaining procedures, there can be no recovery.ician" means a person licensed to practice medicine in the State or in the jurisdiction where the treatment is to be rendered or withheld. (q) "Terminal condition" means an incurable condition caused onse; and -3- (2) From which, after the passage of a medically appropriate period of time, it can be determined, to a reasonable degree of medical certainty, that there can be no recovery. (p) "Physs of consciousness, exhibiting no behavioral evidence of self-awareness or awareness of surroundings in a learned manner other than reflex activity of muscles and nerves for low level conditioned resplth of an individual; or Prevent the impending death of an individual. "Persistent vegetative state" means a condition caused by injury, disease, or illness: (1) In which a patient has suffered a losy resuscitation. (n) "Medically ineffective treatment" means that, to a reasonable degree of medical certainty, a medical procedure will not: (1) (2) (o) Prevent or reduce the deterioration of the hea recovery from a terminal condition, persistent vegetative state, or end-stage condition. (2) "Life-sustaining procedure" includes artificially administered hydration and nutrition, and cardiopulmonar that: (i) Utilizes mechanical or other artificial means to sustain, restore, or supplant a spontaneous vital function; and (ii) Is of such a nature as to afford a patient no reasonable expectation ofle to communicate by means other than speech may not be considered incapable of making an informed decision. (m) (1) "Life-sustaining procedure" means any medical procedure, treatment, or intervention evaluation of the burdens, risks, and benefits of the treatment or course of treatment, or is unable to communicate a decision. (2) For the purposes of this subtitle, a competent individual who is abtreatment or course of treatment because the patient is unable to understand the nature, extent, or probable consequences of the proposed treatment or course of treatment, is unable to make a rationalividuals. (l) (1) "Incapable of making an informed decision" means the inability of an adult patient to make an informed decision about the provision, withholding, or withdrawal of a specific medical ractitioner or a facility that provides health care to individuals. (2) "Health care provider" includes agents or employees of a health care practitioner or a facility that provides health care to indicle to provide health care; or (2) The administrator of a hospital or a person designated by the administrator in accordance with hospital policy. (k) (1) "Health care provider" means a health care psible condition would be medically ineffective. (j) "Health care practitioner" means: -2- (1) An individual licensed or certified under the Health Occupations Article or § 13516 of the Education Art That has caused severe and permanent deterioration indicated by incompetency and complete physical dependency; and (2) For which, to a reasonable degree of medical certainty, treatment of the irreverl ventilation, defibrillation, and other related life-sustaining procedures. (i) "End-stage condition" means an advanced, progressive, irreversible condition caused by injury, disease, or illness: (1)mergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation including cardiac compression, endotracheal intubation, other advanced airway management techniques, artificiay Medical Services in conjunction with the State Board of Physician Quality Assurance which, in the event of a cardiac or respiratory arrest of a particular patient, authorizes certified or licensed eting an informed decision. (h) "Emergency medical services `do not resuscitate order'" means a physician's written order in a form established by protocol issued by the Maryland Institute for Emergencatment and who has not been determined to be incapable of making an informed decision. (g) "Declarant" means a competent individual who makes an advance directive while capable of making and communicaetermining best interest. (f) "Competent individual" means a person who is at least 18 years of age or who under § 20-102(a) of this article has the same capacity as an adult to consent to medical trereatment or the withholding or withdrawal of the treatment; and (7) The religious beliefs and basic values of the individual receiving treatment, to the extent these may assist the decision maker in d The effect of the treatment on the life expectancy of the individual; The prognosis of the individual for recovery, with and without the treatment; (6) The risks, side effects, and benefits of the tding or withdrawal of treatment result in a severe and continuing impairment of the dignity of the individual by subjecting the individual to a condition of extreme humiliation and dependency; (4) (5)in or discomfort caused to the individual by the treatment, or the withholding or withdrawal of the treatment; (3) The degree to which the individual's medical condition, the treatment, or the withholndividual resulting from that treatment, taking into account: (1) The effect of the treatment on the physical, emotional, and cognitive functions of the individual; -1- (2) The degree of physical paysician who has primary responsibility for the treatment and care of the patient. (e) "Best interest" means that the benefits to the individual resulting from a treatment outweigh the burdens to the ilt appointed by the declarant under an advance directive made in accordance with the provisions of this subtitle to make health care decisions for the declarant. (d) "Attending physician" means the phhe declarant in accordance with the requirements of this subtitle; or (2) A witnessed oral statement, made by the declarant in accordance with the provisions of this subtitle. (c) "Agent" means an adu Advance Medical Directive. § 5-601. (a) In this subtitle the fo llowing words have the meanings indicated. (b) "Advance directive" means: (1) A witnessed written document, voluntarily executed by tical Directive is based on the following Maryland Statutes: "Health General § 5-601 et. Seq." For your convenience, we have included useful relevant excerpts from the Maryland Statutes relating to the The health care agent may not be a witness to your advance directive. At least one of your witnesses may not be a person who may financially benefit by reason of your death. This Maryland Advance Medion and Instruction for Maryland Advance Medical Directive (Power of Attorney for Health Care & Living Will); (2) Maryland Advance Medical Directive (Power of Attorne y for Health Care & Living Will).he event of terminal condition, persistent vegetative state, or end-stage condition. You can also use the adva nce directive to make any other health care decisions. This package contains (1) Informat health care issues, by allowing you to select a health care agent, give health care instructions, or both. By using the Advance Directive, you can make decisions about life-sustaining procedures in tInformation and Instructions Maryland Advance Medical Directive (Power of Attorney for Health Care & Living Will) The Maryland Advance Medical Directive, allows you to make some decisions about future Maryland