Advance
Directives
Appointment of a Health Care Agent
for Health Care Decision-Making
Health Care Instructions
Living Will
Learn about your rights in making
health care decisions
Anne Arundel Medical Center | Advance Directives | About Advance Directives
Information About Your Health-Care Decision-Making Forms
Decisions about whether to prolong life for loved ones who are at the very end stage of life and too inca-
The following forms were created by Maryland law to allow you to decide future health care issues. The
pacitated to decide for themselves place family members under enormous stress. Studies show, in fact,
“Living Will” form allows you to make health care decisions in the future if your health from a terminal con-
that the stress levels associated with end-of-life situations, in the absence of advance directives from the
dition or persistent vegetative state is imminent, despite the application of life-sustaining procedures. The
patient, are among the highest of any kind of personal crisis.
“Appointment of a Health Care Agent” form allows you to select someone to make your health care decisions in case of a terminal condition, persistent vegetative state, or end-stage condition. The “Health Care
However, these same studies also suggest that having advance directives in place greatly reduces stress,
Instructions” form provides instructions to your health care agent or physician. This final form, provided by
allowing family members to focus more on their loved one’s quality of life during the time remaining. They
Anne Arundel Medical Center, covers further decisions regarding your health care that you may want to dis-
are relieved of the awful responsibility and painful conflicts they inevitably face in decisions concerning
cuss with your appointed health care agent.
when or if to stop life support.
Please note: If you select a health care agent, that person may not be a witness to your advance directives.
Advance directives are a way to take control of end-of-life decisions now, before the fact, when there is time
Your witnesses may not be anyone who may financially benefit from your death. You should also make
for reflection and when informed, intelligent choices can be made.
three copies of your forms, sending one to your health care agent, one to your doctor and the third to your
medical facility. Your health care facility will ask you for a copy of your advance directives when you are
admitted to the hospital. Please have a copy of these forms with you if possible. If you have any questions
regarding this packet, please contact AAMC Patient Advocacy at 443-481-4820.
Inserted in this brochure you will find wallet cards for Maryland Advance Directives. Please detach them
and complete the required information. Put the cards in the wallet or purse you carry most often, along
with your driver’s license or health insurance card.
Anne Arundel Medical Center | Advance Directives | Anne Arundel Medical Center | Advance Directives | Appointment of Health Care Agent
1. I, _______________________________________________________________, born on ___________________________,
and residing at _______________________________________________________________________________________
4. My agent shall not be liable for the costs of care based solely on this authorization.
5. My agent’s authority goes into effect:
________ When my attending physician and second physician determine that I am incapable of making an informed
__________________ __________________________________________________________________________________
decision regarding my health care; or
appoint the following individual as my agent to make health care decisions for me:
________ When this document is signed.
Name: ____________________________________________
Address:_____________________________________________________________________________________________
Phone:_________________________________
6. This power is subject to the following conditions or limitations: (optional; form valid if left blank)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
2. Optional: If this agent is unavailable or is unwilling to act as my agent when needed, then I give my permission to the
____________________________________________________________________________________________________
following person to act in this capacity:
Alternate Agent #1:
Name:______________________________________________
7. People my agent should consult when making important decisions on my behalf. 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 decisions.
Address:_____________________________________________________________________________________________
Phone:___________________________________
Name:
Alternate Agent #2:
___________________________________________ __________________
Name:______________________________________________
___________________________________________ __________________
Address:_____________________________________________________________________________________________
___________________________________________ __________________
Phone:___________________________________
3. My agent has full power of authority to make health care decisions for me, including the power to:
a. Request, receive, and review any information, regarding my physical or mental health, as well as any other docu-
___________________________________________ __________________
8. The authority of my agent is subject to the following provisions and limitations (optional, valid if blank):
____________________________________________________________________________________________________
ments that involve my welfare. (Ex. Medical and hospital records)
____________________________________________________________________________________________________
b. 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 forms.
c. Decide whom my doctor and other health care providers should be.
d. Decide where I should be treated; including whether I should be in a hospital, nursing home, hospice, or other
9. Statement of Goals and Values:
I want to say something about my goals and values, and especially what’s most important to me during the last part of
medical care facilities.
my life (optional, valid if left blank):
e. Decide whether or not to provide or withhold health care treatments, including life-sustaining procedures.
____________________________________________________________________________________________________
f. Make decisions for me based on the health-care instructions I give in this document and wishes known to my
____________________________________________________________________________________________________
agent. If my wishes are unknown or unclear, my agent is to make health-care decisions for me with my best inter-
____________________________________________________________________________________________________
ests in mind. My agent should determine this after considering the benefits, burdens, and risks that may result
from a given treatment, or from the withholding/withdrawal of a treatment.
g. I also want my agent to:
Telephone Number(s):
10. Preference in Case of Terminal Condition
(If you want to state what your preference is, initial only one. If you do not want to state a preference here, cross
i. Ride with me in an ambulance if needed and permitted by EMT’s; and
through the whole section.)
ii. Be able to visit me if conditions and space allow if in a hospital or other health care facilities.
If my doctors certify that my death from a terminal condition is imminent, even if life-sustaining procedures are used:
_______ a. 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.
| Anne Arundel Medical Center | Advance Directives
Anne Arundel Medical Center | Advance Directives | _______ b. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try
_______ c. Try to extend my life for as long as possible, using all available interventions that in reasonable medical
to extend my life. If I am unable to take enough nourishment by mouth, however, I want to receive nutrition and fluids
judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive
by tube or other medical means.
nutrition and fluids by tube or other medical means.
_______ c. Try to extend my life for as long as possible, using all available interventions that in reasonable medical
_______ d. I direct that if I am brain dead, an anatomical gift be offered on my behalf to a patient in need of an organ
judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive
or tissue transplant. If a transplant occurs, I want an artificial heart/lung support devices to be continued on my behalf
nutrition and fluids by tube or other medical means.
only until organ or tissue suitability of the patient is confirmed and organ or tissue recovery has taken place.
_______ d. I direct that if I am brain dead, an anatomical gift be offered on my behalf to a patient in need of an organ
or tissue transplant. If a transplant occurs, I want an artificial heart/lung support devices to be continued on my behalf
only until organ or tissue suitability of the patient is confirmed and organ or tissue recovery has taken place.
13. Pain Relief
_______ a. I want to be given medication for pain and suffering, even if it would shorten my remaining life.
_______ b. I do not want to be given medication for pain and suffering, even if it would shorten my remaining life.
11. Preference in Case of Persistent Vegetative State
(If you want to state what your preference is, initial only one. If you do not want to state a preference here, cross
14. In Case of Pregnancy
through the whole section.)
If I am pregnant, my decision concerning life-sustaining procedures shall be modified as follows:
If my doctors certify that I am in a persistent vegetative state, this 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 con-
____________________________________________________________________________________________________
sciousness:
____________________________________________________________________________________________________
_______ a. 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.
_______ b. Keep me comfortable and allow natural death to occur. I do not want any medical interventions used to try
15. Effect of Stated Preference (Read both statements carefully. Then initial only one.)
to extend my life. If I am unable to take enough nourishment by mouth, however, I want to receive nutrition and fluids
_______ a. I realize I cannot foresee everything that might happen after I can no longer decide for myself. My stated
by tube or other medical means.
preferences are meant to guide whoever is making decisions on my behalf and my health care providers, but I authorize
_______ c. Try to extend my life for as long as possible, using all available interventions that in reasonable medical
them to be flexible in applying these statements if they feel that doing so would be in my best interest.
judgment would prevent or delay my death. If I am unable to take enough nourishment by mouth, I want to receive
_______ b. I realize I cannot foresee everything that might happen after I can no longer decide for myself. Still, I want
nutrition and fluids by tube or other medical means.
whoever is making decisions on my behalf and my health care providers to follow my stated preferences exactly as writ-
_______ d. I direct that if I am brain dead, an anatomical gift be offered on my behalf to a patient in need of an organ
ten, even if they think that another alternative is better.
or tissue transplant. If a transplant occurs, I want an artificial heart/lung support devices to be continued on my behalf
only until organ or tissue suitability of the patient is confirmed and organ or tissue recovery has taken place.
12. Preference in Case of End-Stage Condition
(If you want to state what your preference is, initial only one. 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-state 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:
_______ a. 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.
_______ b. Keep me comfortable and allow natural death to occur. I do not want any 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.
| Anne Arundel Medical Center | Advance Directives
Anne Arundel Medical Center | Advance Directives | After My Death
PART III: DISPOSITION OF BODY AND FUNERAL ARRANGEMENTS
(This document is optional. Do only what reflects your wishes.)
By; _________________________________________________ Date of Birth _______________________________________
(Print Name)
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.)
(Month/Day/Year)
_______ The health care agent who I named in my advance directive.
PART I: ORGAN DONATION
OR
This person:
(Initial the ones that you want. Cross through any that you do not want.)
Name __________________________________________________________________________________________________
Address ________________________________________________________________________________________________
Upon my death I wish to donate:
_______________________________________________________________________________________________________
_______ Any needed organs, tissues, or eyes.
Telephone Number(s) _____________________________________________________________________________________
_______ Only the following organs, tissues, or eyes:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
I authorize the use of my organs, tissues, or eyes:
_______ For transplantation
_______ For therapy
(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 react to other people's funeral
arrangements. My wishes about the disposition of my body and my funeral arrangements are:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______ 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.
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,
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)
tissue, and eye recovery has been completed. I understand that my estate will not be charged for any costs related to this
donation.
The Donor signed or acknowledged signing the foregoing document in my presence and, based upon personal observation,
appears to be emotionally and mentally competent to make 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.
_________________________________________________________________________
(Signature of Witness)
_ __________________________
( Date)
_________________________________________________________________________
(Telephone Number)
_________________________________________________________________________
(Signature of Witness)
_ __________________________
( Date)
_________________________________________________________________________
| Anne Arundel Medical Center | Advance Directives
(Telephone Number)
Anne Arundel Medical Center | Advance Directives | 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)
Did You Remember To...
o Fill out Part I if you want to name a health care agent?
o Name one or two back-up agents in case your first choice as
health care agent is not available when needed?
_________________________________________________________________________
(Telephone Number)
_________________________________________________________________________
(Signature of Witness)
o Talk to your agents and back-up agent about your values and
_ __________________________
( Date)
_________________________________________________________________________
priorities, and decide whether that’s enough guidance or
whether you also want to make specific health care decisions in
the advance directive?
(Telephone Number)
o If you want to make specific decisions, fill out Part 11, choosing
(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
carefully among alternatives?
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.)
o Sign and date the advance directive in Part III, in front of two
witnesses who also need lo sign?
o Look over the “After My Death” form to see if you want to fill out
any part of it?
o Make sure your health care (if you named one), your family, and
your doctor know about your advance care planning?
o Give a copy of your advance directive to your health care agent
family members, doctor, and hospital or nursing home if you are
a patient there?
| Anne Arundel Medical Center | Advance Directives
Anne Arundel Medical Center | Advance Directives | Rev. 10/06
Anne Arundel Medical Center | Advance Directives | 11
spine fold
_____________________________________________________
__________________________________ for more information.
__________ ___________________________________________
_____________________________________________________
__________________________________ for more information.
__________ ___________________________________________
Signature
(Date)
(Health Care Provider or Agent)
(Health Care Provider or Agent)
(Date)
Please contact: ________________________________________
Please contact: ________________________________________
Signature
(Address)
I have given instructions concerning advance Directives and/or
organ donation in the following documents (check one or both):
______ Maryland Living Will Declaration
______ Appointment of Health Care Agent
I have given instructions concerning advance Directives and/or
organ donation in the following documents (check one or both):
______ Maryland Living Will Declaration
______ Appointment of Health Care Agent
(Address)
Maryland Advance directives Card
Maryland Advance directives Card
license or health insurance card.
Cut out and complete the cards below. Put the cards in the wallet or purse you carry most often, along with your driver’s
Wallet Cards for Maryland Advance Directives