Fillable Advance Directive: Treatment Preferences (Living Will) - You

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Advance Directive: Treatment Preferences (Living Will) - You

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State of ______________
LIVING WILL
Advance Directive: Treatment Preferences (“Living Will”) - You have the right to use an advance directive
to say what you want about future life-sustaining treatment issues. It lets you decide about life-sustaining
procedures in three situations: when death from a terminal condition is imminent despite the application of
life-sustaining procedures; a condition of permanent unconsciousness called a persistent vegetative
state; and end-stage condition, which is an advanced, progressive, and incurable condition resulting in
complete physical dependency. You may complete all or only part of the forms that you use. Different
forms may also be used.
A. Preference in Case of Terminal Condition
(If you want to state what your preference is, initial one only. If you do not want to state a preference here,
cross through the whole section.)
If my doctors certify that my death from a terminal condition is imminent, even if life-sustaining procedures
are used:
______ 1. 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.
OR
______ 2. Keep me comfortable and allow natural death to occur. I do not want 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.
OR
______ 3. Try to extend my life for as long as possible, using all available interventions that
in reasonable medical judgment would prevent or delay my death. If I am unable to take enough
nourishment by mouth, I want to receive nutrition and fluids by tube or other medical
means.
B. Preference in Case of Persistent Vegetative State
(If you want to state what your preference is, initial one only. If you do not want to state a preference here,
cross through the whole section.)
If my doctors certify that I am in a persistent vegetative state, that 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 consciousness:
______ 1. 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.
OR
______ 2. Keep me comfortable and allow natural death to occur. I do not want 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.
OR
______ 3. Try to extend my life for as long as possible, using all available interventions that in
reasonable medical judgment would prevent or delay my death. If I am unable to take enough
nourishment by mouth, I want to receive nutrition and fluids by tube or other medical
means.
C. Preference in Case of End-Stage Condition
(If you want to state what your preference is, initial one only. 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:
______ 1. 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.
OR
______ 2. Keep me comfortable and allow natural death to occur. I do not want 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.
OR
______ 3. Try to extend my life for as long as possible, using all available interventions that in
reasonable medical judgment would prevent or delay my death. If I am unable to take enough
nourishment by mouth, I want to receive nutrition and fluids by tube or other medical
means.
D. Pain Relief
No matter what my condition, give me the medicine or other treatment I need to relieve pain.
E. In Case of Pregnancy
(Optional, for women of child-bearing years only; form valid if left blank)
If I am pregnant, my decision concerning life-sustaining procedures shall be modified as follows:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
F. Effect of Stated Preferences
(Read both of these statements carefully. Then, initial one only.)
______ 1. I realize I cannot foresee everything that might happen after I can no longer decide for
myself. My stated preferences are meant to guide whoever is making decisions on my behalf and my
health care providers, but I authorize them to be flexible in applying these statements if they feel that
doing so would be in my best interest.
OR
______ 2. I realize I cannot foresee everything that might happen after I can no longer decide for
myself. Still, I want whoever is making decisions on my behalf and my health care providers to follow
my stated preferences exactly as written, even if they think that some alternative is better.
SIGNATURES AND WITNESSES
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 ____________________
Print Name _______________________________________________________
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 ____________________
Print Name _______________________________________________________
Signature of Witness _________________________ Date ____________________
Print Name _______________________________________________________
Please note: If you selected a health care agent, that person may not be a witness. Also, at least one of
the witnesses must be 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.
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Advance Directive: Treatment Preferences (Living Will) - You

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Completed 3 February 2022

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