Maryland Living Will
This Living Will is created in accordance with the laws of the State of Maryland. It expresses my wishes regarding medical treatment in the event that I become unable to communicate my preferences.
Individual Information:
- Name: ______________________________
- Date of Birth: ______________________
- Address: ____________________________
- City, State, Zip Code: ______________
Declaration:
I, the undersigned, being of sound mind, willfully and voluntarily make this declaration regarding my medical treatment. If I become unable to make my own healthcare decisions, I direct that:
- Life-sustaining treatment should be withheld or withdrawn if:
- I have a terminal condition.
- I am in a persistent vegetative state.
- I am suffering from an irreversible condition that will result in my death.
- In such circumstances, I wish to receive:
- Comfort care only.
- Pain relief measures, even if they may hasten my death.
Appointment of Healthcare Agent:
If I am unable to make my own healthcare decisions, I appoint the following individual as my healthcare agent:
- Name: ______________________________
- Address: ____________________________
- Phone Number: ______________________
Signatures:
This Living Will is executed on the _____ day of __________, 20__.
Signature: ____________________________
Witness 1: ____________________________
Witness 2: ____________________________
Notary Public:
State of Maryland
County of ____________________________
Subscribed and sworn to before me this _____ day of __________, 20__.
Notary Signature: ______________________
My Commission Expires: ________________