Maryland Advance Directive Form

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Updated June 17, 2022

A Maryland advance directive is a document that allows a person to select a health care agent and choose their end-of-life treatment options. The form is required to be signed with two (2) witnesses and kept in a safe and accessible place.

Four (4) Parts

  1. Selection of Health Care Agent (“Medical Power of Attorney”)
  2. Treatment Preferences (“Living Will”)
  3. Signature and Witness
  4. After my Death

Table of Contents

Laws

Statute – § 5-601 to § 5-618 (Maryland Health Care Decisions Act)

Signing Requirements (MD Code, Health – General, § 5-602) – The advance directive must be subscribed by two (2) witnesses in the physical presence or electronic presence of the declarant.

State Definition (MD Code, Health – General, § 5–601(b)) – “Advance directive” means a witnessed written or electronic document, voluntarily executed by the declarant in accordance with the requirements of this subtitle.

Versions (5)


AARP

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Frederick Health

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Kaiser Permanente

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Mental Health Assoc.

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Statutory Version

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How to Write

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Preliminary Maryland Health Care Principal Information

(1) Name Of Maryland Declarant. This declaration of medical treatment preferences of the Maryland Health Care Principal must begin with the identity of the Declarant issuing it. Furnish his or her full name to the first line of this document. The Maryland Declarant, or Health Care Principal, will be the Party whose intent is to use this paperwork as a means to authorize a specific Agent to medical treatment decisions on his or her behalf when needed.

(2) Date Of Maryland Declarant Birth. The calendar date of the Maryland Declarant’s birthday must be reported to aid in identifying him or her through this document.

I. Selection Of Health Care Agent

A. Selection Of Primary Health Care Agent

(3) Name Of Maryland Health Care Agent. The Health Care Agent who will be authorized by the Principal to assume the right to make medical treatment decisions on his or her behalf must be clearly identified in Part I. Present the full name of the Maryland Declarant’s chosen Primary Health Care Agent on the first line of Statement (A). Document his or her name as recorded on the Primary Health Care Agent’s government-issued identification (such as a State Driver’s/Non-Driver’s ID or Passport).

(4) Address Of Maryland Health Care Agent. Since a significant amount of responsibility is being granted to the Maryland Health Care Principal’s Agent, this Agent (or Attorney-in-Fact) must be further identified with a presentation of his or her physical home address.

(5) Contact Telephone Numbers. The Maryland Principal’s Primary Health Care Agent may have to be reached through the information in this document, therefore a record of his or her home phone number and cellular telephone number should be presented.

(6) Alternate Health Care Agent Name. Notice that Statement (A) continues with a precautionary option the Maryland Declarant may take advantage of (if desired). This paperwork allows the Maryland Health Care Principal to name a Back-up Health Care Agent. This can be considered particularly useful in a scenario where the Maryland Principal requires his or her Primary Health Care Agent’s actions and powers in this role to be engaged but is unable to act due to a revocation of his or her powers, suddenly becoming unavailable for a long period of time (i.e. deployed as Military Personnel or traveling). However, if a Back-Up Agent is appointed in this document, then he or she will be able to assume the principal power needed to make medical decisions for the Declarant (or Principal) without further action on the Principal’s part at a time when the Maryland Health Care Principal (or Declarant) is unconscious or otherwise unable to communicate with Medical Personnel.

(7) Address And Telephone Numbers Of Alternate Agent. Dispense the home address of the Back-Up Agent along with his or her home and cell phone numbers where requested.

(8) Second Alternate Health Care Agent Identity. While the role of the Back-Up Agent will be to function as an immediate replacement for the Primary Agent, a Second Back-Up Agent can be set in place to assume the medical decision making responsibilities that the Primary Health Care Agent and First Back-Up Agent will be counted upon to make but are both unable or unwilling. In order for a Second Back-Up Agent to be set in place, his or her name must be presented where requested. It should be mentioned that neither the First or Second Back-Up Agent will be given the ability to decide upon the Maryland Principal’s medical treatment unless the Primary Health Care Agent has vacated this role. A Back-Up Agent will be granted power only as a matter of succession and in the order that is named in this document.

(9) Address And Telephone Numbers. The complete address of the Second Back-Up Agent as well as his or her home telephone number and cellular telephone number must be presented to the spaces requesting this information.

(10) Additional Directives For Agents And Medical Staff. The Maryland Principal behind this declaration has the option of directly addressing the Health Care Agent(s) and Medical Staff attending to his or her treatment. This opportunity allows the Maryland Principal to discuss medical procedures that he or she prefers or wishes to avoid, place contingencies on possible future treatment decisions the Health Care Agent may be called upon to make, or even forbid certain treatments. In short, the concerns, preferences, and aversions regarding his or her medical treatment can be plainly stated in Part I by the Maryland Health Care Principal so long as they are considered legal.

D. How My Agent Is To Decide Specific Issues

(11) Desired Consultations. The Principal may wish his or her Primary Health Care Agent to discuss his or her medical condition and possible treatments with certain Parties such as a Family Member, a Good Friend, a Member of the Clergy, or his or her Spouse. If so, the full name and contact telephone numbers of each Party the Maryland Health Care Principal wishes or suggests to be consulted by the Health Care Agent when making treatment decisions for the Principal should be documented in Part I.

F. In Case Of Pregnancy

(12) Pregnancy Contingency. In some cases, there may be a potential that the Maryland Principal become incapacitated and in need of medical attention while pregnant. If so, then Section E may be used to present the Maryland Principal’s medical directives and preferences when pregnant.

H. Effectiveness

(13) Immediate Medical Decision Making Powers. This directive may be put in effect as soon as it is signed by the Maryland Health Care Principal if he or she initials the Statement (1) in Section (H).

(14) Postponed Access To Medical Decision Making Powers. If the Maryland Principal intends for this document to grant the Primary Health Care Agent principal power only upon the Maryland Health Care  Principal’s incapacitation, then Statement (2) must be initialed by the Maryland Health Care Principal.

II. Living Will

A. Statement Of Goals And Values

(15) Statement Of Goals And Values. This declaration enables the Maryland Health Care Principal to deliver a statement defining his or her preferences when he or she is enduring an end-of-life event where no known treatment will prolong life and is unable to voice his or her wishes. This area will accept discussions regarding the personal comfort and emotional support needs of the Maryland Health Care Principal as well as his or her preferences over medical treatment and will aid in determining the Principal’s desired quality of life (during and after treatment).

B. Preferences In Case Of Terminal Condition

Initial Item 16 Or Initial Item 17 Or Initial Item 18

(16) Refusing Medical Intervention And Artificial Nutrition. The Maryland Health Care Principal can use this paperwork to formally deny medical intervention and the administration of artificially delivered nutrition and hydration when he or she endures a terminal condition. This is a condition that is considered untreatable by medical science and will result in death. To adopt the directive that medical intervention should be denied if a life-threatening medical event strikes the Principal when he or she has been diagnosed with a terminal condition and that all medically delivered food and water be withheld while enduring a terminal condition, the Maryland Health Care Principal must initial Statement 1 from “Preferences In Case Of Terminal Condition.”

(17) Accepting Artificial Nutrition But Refusing Intervention. The Maryland Health Care Principal can choose to accept nutrition and water to be delivered through artificial means yet refuse medical intervention geared to prolonging his or her life when suffering a terminal (fatal) medical condition by intialing the second statement made in “B. Preferences In Case Of Terminal Condition.”

(18) Accepting Medical Intervention And Artificial Nutrition. If the Maryland Health Care Principal has been diagnosed with a terminal condition that will result in death and he or she wishes to inform all attending Medical Personnel (and his or her Health Care Agent) that all medical interventions possible be delivered when needed to prolong life and that he or she authorizes the assisted delivery of nutrition and hydration to prevent starvation or dehydration, then he or she must initial the final statement option made in “B Preferences In Case Of Terminal Condition.”


C. Preference In Case Of Persistent Vegetative State

Initial Item 19 Or Initial Item 20 Or Initial Item 21

(19) Refusing All Intervention And Artificial Nutrition. This document can be used to deny medical treatment and artificially delivered nutrition/hydration (i.e. tube feeding) from being administered to the Maryland Health Care Principal in an effort to prolong life if he or she is declared as being in a persistent or permanent vegetative state from which he or she has little to no chance for recovering consciousness. For this effect, the Maryland Principal must initial the first statement made by “C. Preference In Case Of Persistent Vegetative State.”

(20) Refusing Medical Intervention And Accepting Artificial Nutrition. The option to present the Maryland Health Care Principal’s formal refusal of any medical treatment designed to extend the Maryland Health Care Principal’s life when he or she is in a permanent vegetative state while still authorizing the delivery of nutrition and hydration (even if medically) is available through this document. In order to make this directive effective, Statement (2) presented in this area must be initialed by the Maryland Health Care Principal.

(21) Accepting Both Artificial Nutrition And Medical Intervention. If the Maryland Health Care Principal is diagnosed as being in a permanent vegetative state but intends to accept all life-prolonging treatment such as medically assisted feedings, hydration, and interventions or treatment to aid in surviving a life-threatening medical event (i.e. kidney failure), then the third option under “C. Preference In Case Of Persistent Vegetative State” should be initialed by the Maryland Health Care Principal.

D. Preference In Case Of End-Stage Condition

Initial Item 22 Or Initial Item 23 Or Initial Item 24

(22) Denying Medical Intervention And Artificial Nutrition. When a Maryland Patient enters the end-stage of a terminal condition, attending Staff will seek to intervene through medical treatment and if necessary the assisted delivery of nutrition/hydration directly to the Patient. If the Maryland Health Care Principal is diagnosed as entering the end stage of a terminal condition or untreatable injury and wishes to deny all intervention as well as medically delivered nutrition and water, then he or she must initial Statement (1) from “D. Preference In Case Of End-Stage Condition.”

(23) Accepting Artificial Nutrition Only. The Maryland Health Care Principal may wish to deny Medical Staff from providing any medical treatment meant to prolong the end-of-life event he or she is enduring but wishes to remain well-fed and well-hydrated (even if this requires medical assistance). If the Maryland Health Care Principal initials the second statement in “D. Preference In Case Of End-Stage Condition” then he or she will only be issuing a formal refusal of life-saving medical interventions during an end-stage condition while approving the maintenance of his or her nutrition and hydration levels even through artificial feedings.

(24) Accepting Medical Intervention And Artificial Nutrition. Statement (3) in “D. Preferences In Case Of End-Stage Condition” should only be initialed by the Declarant (Principal) if he or she intends to accept all medical treatment and interventions as well as authorize tube feedings and other methods of delivering nourishment and liquids while enduring an end-stage condition.

E. Pain Relief

(25) Authorizing Pain Management And Relief. If the Maryland Health Care Principal wishes to accept all pain management medication and treatment so that he or she can be kept as pain-free as possible regardless of his or her medical condition and the likelihood of survival, then he or she must initial the statement made by Section “E. Pain Relief.”

F. In Case Of Pregnancy

(26) Directives When Pregnant. Section F shall accept instructions and decisions on the life-prolonging procedures and medications that the Maryland Health Care Principal will accept when pregnant as well as those that she wishes to deny or refuse when pregnant, suffering a terminal condition, and unable to communicate.

G. Effect Of Stated Preferences

Initial Item 27 Or Initial Item 28

(27) Flexible Health Care Directives. The decisions, authorizations, and refusals of treatments and medications when incapacitated that are presented in this document can be set as uncompromising directives made by the Maryland Health Care Principal or be considered flexible since medical technology can advance rapidly in some areas. If the Maryland Health Care Agent should be given a certain amount of flexibility when making decisions regarding the treatment administered to the Principal, then this must be authorized by the issuing Health Care Principal. To formally authorize the Maryland Health Care Agent to diverge from the directives set by the Principal when he or she believes it is an appropriate balance between the Principal’s preferences and the current medical technology of the time, then the first statement in “G. Effect Of Stated Preferences” should be initialed by the Principal.

(28) Stringent Health Care Directives. The Maryland Health Care Principal can set the directives and instructions this document contains to be the final official medical preferences he or she wishes stringently followed until a new set of directives are issued or until he or she formally amends this paperwork. To do so the Maryland Health Care Principal must initial Statement (2) found in “G. Effect Of Stated Preferences.”

III. Signature And Witnesses

(29) Signature Of Declarant. While some areas of this document may have been prepared ahead of time by someone aiding the Declarant, only the Maryland Health Care Principal (Declarant) will be allowed to provide his or her initials to the statements made above and place this directive in effect through his or her authorizing signature. Therefore, once he or she has carefully reviewed the above directives, the attachments affixed to this paperwork, and completed all the necessary consultations (i.e. his or her Physician and Health Care Agent), the Maryland Health Care Principal should gather with two Witnesses then sign his or her name as the Declarant.

(30) Date. After delivering his or her signature, the Maryland Health Care Principal must submit the calendar date of the day at the time of signing.

(31) Telephone Numbers. Both the home telephone number as well as the cellular telephone number of the Maryland Health Care Principal should be displayed below his or her signature and signature date.

(32) Signature Of Witnesses. Two distinct areas have been supplied so that each Witness may provide his or her testimonial signature. Once Both Witnesses have observed the signing of this document by the Maryland Health Care Principal, each one must sign his or her name. The signature provided by each Witness will act as an acknowledgment to the testimonial paragraph above it.

(33) Date. Both Witnesses must supply their respective dates of signature where requested.

(34) Telephone Numbers. Each Witness must present his or her home and cell phone number to the spaces provided.

After My Death (Optional)

(35) Maryland Declarant Name. This directive package continues with an opportunity to establish the position of the Maryland Declarant (Health Care Principal) regarding anatomical gifts such as organ donations to science as well as other wishes that he or she wishes engaged after death. If he or she chooses to continue a discussion regarding his or her post-death wishes, then the full name of the Maryland Health Care Principal should be presented on the first line following the title “After My Death.”

(36) Date Of Birth. The date of the Maryland Declarant’s birth is required where requested as support for his or her identity.

Part I. Organ Donation

Initial Item 37 Or Initial Item 38 And Complete Item 39

(37) Donating All Needed Organs. If the Maryland Declarant issuing the directives package above wishes to declare that he or she wishes to donate “Any Needed Organs, Tissues, Or Eyes” after death then the first available space in “Part I. Organ Donation” must bear the initials of the Maryland Declarant (Health Care Principal).

(38) Selecting Organs For Donation. If the Maryland Declarant wishes to make anatomical gifts but only certain parts, then he or she must initial the second statement that is presented in “Part I: Organ Donation.”

(39) Approved Donation. After indicating that only certain body parts should be made into anatomical gifts upon his or her death, the Maryland Declarant must provide a record of each body part, organ, tissue, bone, and/or eye/eye part that bear his or her authorization to be donated upon death.

Initial Every Appropriate Statement From Item 40 Or Initial Item 41

(40) Authorized Purpose(s) Of Organ Donation. Several reasons for requiring an anatomical gift have been presented in this section. Each reason that the Maryland Declarant wishes to authorize for an anatomical gift should bear his or her initials. For example, if the Maryland Declarant initials the reasons “For Transplantation” and “For Therapy” then only these reasons for making an anatomical gift will be acceptable while the remaining reasons “For Research” and “For Medical Purpose” will be considered unauthorized by the Maryland Declarant.

(41) Authorizing All Legal Anatomical Gifts. If the Maryland Principal wishes to approve any legal purpose for making an anatomical donation, then the final statement should be initialed.

Part II Donation Of Body

(42) Body Donation Directive. If the Maryland Declarant has approved anatomical gifts and wishes that any remaining body part be donated to a medical study program then he or she must initial the space available in “Part II: Donation Of Body.”

Part III. Disposition Of Body And Funeral Arrangements

(43) Assigned Health Care Agent. The topic of the disposition of his or her body as well as his or her funeral arrangements can be covered by the Maryland Declarant behind this document in Part III. If desired, the Maryland Declarant can designate the same Health Care Agent named in his or her medical directives by initialing the first statement made in “Part III: Disposition Of Body And Funeral Arrangements.

(44) Designating Power Of Body Disposition. A specific person can be designated as the Maryland Declarant’s Final Disposition Agent once he or she grants the authority to handle the disposition of his or her body and funeral arrangements. If this will not be the Maryland Principal’s Health Care Agent, then the Principal must initial the line labeled “This Person.”

(45) Designated Party. Naturally, if the second option has been initialed by the Maryland Declarant in Part III, then the Maryland Health Care Principal’s desired Disposition Agent must be identified. His or her full name, complete home address, home telephone number, and cellular phone number should be documented.

(46) Specific Wishes Regarding Disposition And Funeral. The final area will accept the full instructions of the Maryland Declarant regarding the disposition of his or her body and his or her preferred funeral arrangements. Topics ranging from specific requests to where the funds for his or her post-life preferences should be determined, then be recorded in this area.

Part IV Signature And Witnesses

(47) Signature Of Donor. Since the Maryland Health Care Principal is issuing this post-death declaration, he or she must sign as the Donor behind it on the space provided.

(48) Date Of Donor Signature. The calendar date when the Donor’s signature is submitted must be documented at the time of signing by the Signature Donor (Maryland Health Care Principal).

(49) Signature Of Witness. Two Witnesses must watch the Donor sign this document then read the testimonial paragraph. If these two acts are completed and the Witnesses wish to confirm the testimonial as true, then each one must attend to a separate area by signing the “Signature Of Witness” line. Two Witness signature areas have been provided for this purpose.

(50) Date of Witness Signatures. Each Witness must date his or her signature with a record of the current date on the day of signing.

(51) Telephone Numbers. Both Witness signature areas also request that each Witness supply his or her permanent home telephone number and current cell phone number.

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