Maryland Living Will Template
This Living Will template is designed to comply with the Maryland Health Care Decisions Act. It allows you to express your wishes about medical treatment in the event that you become unable to communicate your decisions. It is important to fill out this document carefully and review it regularly to ensure it reflects your current wishes.
Personal Information
Name: ___________________________________________________________
Date of Birth: ______________________
Address: _________________________________________________________
City: _________________________ State: MD Zip Code: _______________
Health Care Instructions
In the event that I become incapacitated and am unable to communicate my wishes directly, I direct that my health care providers and family or other individuals who are involved in my care follow the instructions provided in this document.
- Life-Sustaining Treatment
If I am in a terminal condition, a persistent vegetative state, or an end-stage condition, and am unable to make my own health care decisions, I direct that:
- All treatments that might extend my life be provided.
- All treatments that might extend my life be withheld or withdrawn, except as necessary to keep me comfortable.
- Specific instructions regarding life-sustaining treatment (please specify): ______________________________________________________
- Artificial Nutrition and Hydration
If I am unable to take food or water by mouth, I wish to receive artificially provided nutrition and hydration:
- Yes, under any circumstances.
- No, I do not want to receive artificial nutrition and hydration.
- Yes, but only if my physician believes it will provide comfort.
- Specific instructions regarding artificial nutrition and hydration (please specify): ___________________________________________
- Additional Instructions
You may provide any additional instructions regarding your health care wishes below:
__________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________
Primary Health Care Agent
If I am unable to make my own health care decisions, I designate the following individual as my primary health care agent:
Name: ___________________________________________________________
Relationship to me: ______________________________________________
Phone number: ________________________ Email: ____________________
Address: _________________________________________________________
Alternate Health Care Agent
If my primary health care agent is unable, unwilling, or unavailable to act on my behalf, I designate the following individual as my alternate health care agent:
Name: ___________________________________________________________
Relationship to me: ______________________________________________
Phone number: ________________________ Email: ____________________
Address: _________________________________________________________
Signature
I understand the contents of this document and I declare that the health care instructions it contains accurately reflect my wishes. This document revokes any prior living will or health care directive I have made.
Signature: _______________________________ Date: _________________
Witness (1) Name: ________________________________________________
Witness (1) Signature: _____________________ Date: ________________
Witness (2) Name: ________________________________________________
Witness (2) Signature: _____________________ Date: ________________
Note: It is recommended that this document be notarized to further validate the authenticity of the signatures.