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Maryland __ 3 _______________ (Witness Signature) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ______________e) Print Name: ___________________________________ Address: ______________________________________ Phone: _______________________________________ Date: ________________ ______________________________edged signing this living will in my presence and based upon my personal observation the declarant appears to be a competent individual. _____________________________________________ (Witness Signaturmake this living will and that I understand its purpose and effect. ______________________ (Date) ____________________________________________ (Signature of Declarant) The declarant signed or acknowliated with my decision to donate my organs, tissues, or eyes or the actual disposition of my organs, tissues, or eyes. 2 By signing below, I indicate that I am emotionally and mentally competent 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 assochorized by law. I understand that before any vital organ, tissue, or eye may be removed for transplantation, I must be pronounced dead. After death, I direct that all support measures be continued to _______________________________ I authorize the use of my organs, tissues, or eyes: _____ For transplantation _____ For therapy _____ For research _____ For medical education _____ For any purpose aut____________________________ d. Upon my death, I wish to donate: _____ Any needed organs, tissues, or eyes. _____ Only the following organs, tissues, or eyes: _______________ _________________________uctions: ______________________________________________________ ______________________________________________________ ______________________________________________________ __________________________ation artificially. _____ I direct that I be given all available medical treatment in accordance with accepted health care standards. 1 c. If I am pregnant my agent shall follow these specific instrtrition and hydration artificially. _____ I direct that my life not be extended by life-sustaining procedures, except that if I am unable to take in food by mouth, I wish to receive nutrition and hydrnd there is no reasonable expectation of my recovery within a medically appropriate period _____ I direct that my life not be extended by life-sustaining procedures, including the administration of nunt in accordance with accepted health care standards. b. If I am in a persistent vegetative state, that is if I am not conscious and am not aware of my environment nor able to interact with others, a, except that, if I am unable to take food by mouth, I wish to receive nutrition and hydration artificially. _____ I direct that, even in a terminal condition, I be given all available medical treatmet my life not be extended by life-sustaining procedures, including the administration of nutrition and hydration artificially. _____ I direct that my life not be extended by life-sustaining procedurestatements which do not apply.) a. If my death from a terminal condition is imminent and even if life-sustaining procedures are used there is no reasonable expectation of my recovery _____ I direct thaon regarding my health care, I direct my health care providers to follow my instructions as set forth below. (Initial those statements you wish to be included in the document and cross through those so the Disclaimers and Terms of Use found at findlegalforms.com A statement of medications preferred by the declarant for psychiatric treatment; Living Will If I am not able to make an informed decisi when dealing with estate planning matters. Any possible tax consequences arising out of this document should be discussed with a tax professional. [_] The purchase and use of these forms is subject tnly be a starting point for you and should not be used or signed without consulting an attorney first to make sure it fits your particular situation. Advice from a local attorney is always recommendeds to their legal effect or completeness. [_]These forms are not intended 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 oant has provided a copy of the directive. [_] These forms are provided "as is" and no implied or express warranties have been made or are provided as to their suitability for any specific purpose or a the substance of the oral revocation in the declarant's medical record. (c) It shall be the responsibility of the declarant, to the extent reasonably possible, to notify any person to whom the declartion of a subsequent directive. (b) If a declarant revokes an advance directive by an oral statement to a health care practitioner, the practitioner and a witness to the oral revocation shall documentn advance directive may be revoked at any time by a declarant by a signed and dated writing, by physical cancellation or destruction, by an oral statement to a health care practitioner or by the execulth services; (3) and (4) Instruction regarding the notification of third parties and the release of information to third parties about mental health services provided to the declarant. § 5-604. (a) Ation of an agent to make mental health services decisions for the (2) The identification of mental health professionals, programs, and facilities that the declarant would prefer to provide mental heato the revocation of an advance directive for mental health services. (d) An advance directive for mental health services may include: Information & Instructions ­ Page 6 (1) declarant; The designae procedures for making an advance directive provided under § 5-602 of this subtitle. (2) The procedures provided under § 5-604 of this subtitle for the revocation of an advance directive shall apply s incompetent and has a need for mental health services either during, or as a result of, the incompetency. (c) (1) An individual making an advance directive for mental health services shall follow thn § 4-301(i)(1) of this article. (b) An individual who is competent may make an advance directive to outline the mental health services which may be provided to the individual if the individual becomedvance directive creates no presumption as to the patient's intent to consent to or refuse life-sustaining procedures. § 5-602.1. (a) In this section, "mental health services" has the meaning stated ilarant's behalf. (h) Unless otherwise provided in the patient's advance directive, a patient's agent shall act in accordance with the provisions of § 5-605(c) of this subtitle. (i) The absence of an aan, a part of the declarant's medical records. (g) It shall be the responsibility of the declarant to notify a health care agent that the agent has been named in an advance directive to act on the declarant's medical records; or (ii) If the advance directive is oral, make the substance of the advance directive, including the date the advance directive was made and the name of the attending physiciician who is notified of the existence of the advance directive shall promptly: (i) If the advance directive is written, make the advance directive or a copy of the advance directive a part of the deche event the declarant becomes comatose, incompetent, or otherwise incapable of communication, any other person may notify the physician of the existence of an advance directive. (2) An attending physhysician is not required under paragraph (1) of this subsection. (f) (1) It shall be the responsibility of the declarant to notify the attending physician that an advance directive has been made. In tt Information & Instructions ­ Page 5 the patient is incapable of making an informed decision. (2) If a patient is unconscious, or unable to communicate by any means, the certification of a second pn and the witness. (e) (1) Unless otherwise provided in the document, an advance directive shall become effective when the declarant's attending physician and a second physician certify in writing thaician and one witness and if the substance of the oral advance directive is documented as part of the individual's medical record. The documentation shall be dated and signed by the attending physiciaappoint an agent to make health care decisions for the individual. (2) An oral advance directive shall have the same effect as a written advance directive if made in the presence of the attending physeason of the death of the declarant. (d) (1) Any competent individual may make an oral advance directive to authorize the providing, withholding, or withdrawing of any life-sustaining procedure or to as a witness. (iii) At least one of the witnesses must be an individual who is not knowingly entitled to any portion of the estate of the declarant or knowingly entitled to any financial benefit by rtness to an advance directive, including an employee of a health care facility or physician caring for the declarant if acting in good faith. (ii) The health care agent of the declarant may not serve igned by or at the express direction of the declarant, and subscribed by two witnesses. (2) (i) Except as provided in items (ii) and (iii) of this paragraph, any competent individual may serve as a wisubtitle has decision making priority over any individuals otherwise authorized under this subtitle to make health care decisions for a declarant. (c) (1) A written advance directive shall be dated, slarant is receiving health care may not serve as a health care agent unless the person would qualify as a surrogate decision maker under § 5-605(a) of this subtitle. (3) An agent appointed under this ting an agent to make health care decisions for the individual under the circumstances stated in the advance directive. (2) An owner, operator, or employee of a health care facility from which the decsion of health care to that individual, or the withholding or withdrawal of health care from that individual. (b) (1) Any competent individual may, at any time, make a written advance directive appoinrom which, despite the application of life-sustaining procedures, there can be no recovery. § 5-602. (a) Any competent individual may, at any time, make a written advance directive regarding the provition & Instructions ­ Page 4 (q) "Terminal condition" means an incurable condition caused by injury, disease, or illness which, to a reasonable degree of medical certainty, makes death imminent and fl certainty, that there can be no recovery. (p) "Physician" means a person licensed to practice medicine in the State or in the jurisdiction where the treatment is to be rendered or withheld. Informativity of muscles and nerves for low level conditioned response; and (2) From which, after the passage of a medically appropriate period of time, it can be determined, to a reasonable degree of medicaase, or illness: (1) In which a patient has suffered a loss of consciousness, exhibiting no behavioral evidence of self-awareness or awareness of surroundings in a learned manner other than reflex ac (1) (2) (o) Prevent or reduce the deterioration of the health of an individual; or Prevent the impending death of an individual. "Persistent vegetative state" means a condition caused by injury, disely administered hydration and nutrition, and cardiopulmonary resuscitation. (n) "Medically ineffective treatment" means that, to a reasonable degree of medical certainty, a medical procedure will not: nature as to afford a patient no reasonable expectation of recovery from a terminal condition, persistent vegetative state, or end-stage condition. (2) "Life-sustaining procedure" includes artificialre" means any medical procedure, treatment, or intervention that: (i) Utilizes mechanical or other artificial means to sustain, restore, or supplant a spontaneous vital function; and (ii) Is of such apurposes of this subtitle, a competent individual who is able to communicate by means other than speech may not be considered incapable of making an informed decision. (m) (1) "Life-sustaining proceduatment or course of treatment, is unable to make a rational evaluation of the burdens, risks, and benefits of the treatment or course of treatment, or is unable to communicate a decision. (2) For the rovision, withholding, or withdrawal of a specific medical treatment or course of treatment because the patient is unable to understand the nature, extent, or probable consequences of the proposed trepractitioner or a facility that provides health care to individuals. (l) (1) "Incapable of making an informed decision" means the inability of an adult patient to make an informed decision about the pmeans a health care practitioner or a facility that provides health care to individuals. Information & Instructions ­ Page 3 (2) "Health care provider" includes agents or employees of a health care of the Education Article 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" , treatment of the irreversible condition would be medically ineffective. (j) "Health care practitioner" means: (1) An individual licensed or certified under the Health Occupations Article or § 13516, disease, or illness: (1) That has caused severe and permanent deterioration indicated by incompetency and complete physical dependency; and (2) For which, to a reasonable degree of medical certaintyment techniques, artificial ventilation, defibrillation, and other related life-sustaining procedures. (i) "End-stage condition" means an advanced, progressive, irreversible condition caused by injuryes certified or licensed emergency medical services personnel to withhold or withdraw cardiopulmonary resuscitation including cardiac compression, endotracheal intubation, other advanced airway manageand Institute for Emergency 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, authorizle of making and communicating 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 Maryl to consent to medical treatment 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 capabst the decision maker in determining 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 adultcts, and benefits of the treatment 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 assiuctions ­ Page 2 (4) (5) 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 efferawal 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; Information & Instrort 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 withholding or withdal resulting from that treatment, taking into account: (1) The effect of the treatment on the physical, emotional, and cognitive functions of the individual; (2) The degree of physical pain or discomf 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 individuinted 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 physicianarant 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 adult appoating to Living Wills. § 5-601. (a) In this subtitle the following words have the meanings indicated. (b) "Advance directive" means: (1) A witnessed written document, voluntarily executed by the declving Will. This Maryland Living Will is based on the following Maryland Statutes: "Health General § 5601 et. Seq." For your convenience, we have included useful excerpts from the Maryland Statutes relminent despite the application of lifesustaining procedures or you are in a persistent vegetative state. This package contains (1) Information and Instruction for Maryland Living Will; (2) Maryland LiInformation and Instructions Maryland Living Will This Living Will form allows you to make some decisions about life-sustaining procedures if, in the future, your death from a terminal condition is im Maryland