Maryland Advance Health Care Directive | Kaiser Permanente of the

MARYLANDAdvance Health Care Directive

LIFE CARE planning

my values, my choices, my care

kp.org/lifecareplan

Document type: Advance directive

Full name: ___________________________________

Medical record number: ______________________

LIFE CARE planning

my values, my choices, my care

Introduction

This advance health care directive lets you share your values, your choices, and your instructions about

your future health care. This form may be used to:

• Name someone you trust to make health care choices for you (your health care agent), OR

• Provide written instructions about your future health care, OR

• Both name a health care agent AND give written instructions for future health care.

Part 1 lets you name a health care agent.

Part 2 gives you a chance to share what is of great value to you.

Part 3 gives your agent written instructions about your future health care.

Part 4 guides your agent’s decision-making by stating your hopes and wishes.

Part 5 makes your advance health care directive legally valid in the state of Maryland.

Part 6 prepares you to share your wishes and this record with others.

People with a terminal health condition can do an oral advance directive in the presence of an attending

physician or nurse practitioner and one witness.

This advance health care directive will replace any advance health care directive you have lled out

in the past. In the future, if you want to cancel or change your named agent, you must sign and date

a written cancellation, physically cancel or destroy your record, or direct someone to do so in your

presence, orally express your wishes to cancel the document to a health care provider and witness, or

execute a new advance directive. Your cancellation becomes effective when you tell your attending

physician.

Full name:

_____________________________________________________________________________

Medical record number: __________________ Date of birth:

__________________________________

Mailing address: _________________________________________________________________________

Home phone:

____________________________

Cell phone:

__________________________________

Work phone:

_________________________________

Email:

__________________________________

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

Part 1. My Health Care Agent

Choosing a health care agent: Choose someone who knows you well, whom you trust to honor your views

and values, and who is able to make hard choices in stressful times.

Once you have picked your health care agent, take the time to talk about your views and care goals with

that person.

If I am not able to communicate my wishes and health care decisions and my doctor and one other

doctor declare in writing that I am not able to make an informed decision about health care, I choose the

following person(s) to honor my wishes and make my health care decisions.

My health care agent must make health care choices that are the same as my instructions in this

document and my known desires. If my agent does not know my wishes, my agent must make health

care choices that he or she believes to be in my best interest, considering what he or she knows about

my values.

This form does not give my health care agent the power to make nancial or other business decisions.

My main health care agent is:

Full name: _____________________________________ Relationship to me:

______________________

Home phone:

_________________________________

Cell phone:

_____________________________

Work phone: __________________________________ Email:

__________________________________

Mailing address: _________________________________________________________________________

If I cancel my main health care agent’s power or if my main agent is not willing or able, I name the

people below as my rst and second alternate agents.

First alternate health care agent:

Full name: _____________________________________ Relationship to me:

______________________

Home phone:

_________________________________

Cell phone:

_____________________________

Work phone: __________________________________ Email:

__________________________________

Mailing address: _________________________________________________________________________

Second alternate health care agent:

Full name: _____________________________________ Relationship to me:

______________________

Home phone:

_________________________________

Cell phone:

_____________________________

Work phone: __________________________________ Email:

__________________________________

Mailing address: _________________________________________________________________________

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

Powers of my health care agent:

Unless I state otherwise, my health care agent has the following powers when I am not able to

speak for myself or make my own choices:

A. Make choices for me about my health care. This involves decisions about tests, medicine, and

surgery. It also involves decisions to provide, not provide, or stop all forms of health care to keep

me alive, as well as tube feedings and IV uids.

B. Review and release my medical records as needed to make decisions.

C. Decide which doctor, health providers, and organizations provide my health care.

D. Arrange for and make decisions about the care of my body after death (including autopsy).

Check the box below if you named your spouse or domestic partner as your agent and you want

your agent to carry on with being your agent even if your marriage or domestic union ends:



I want my agent to stay as my health care agent even if our marriage or domestic union is

dissolved, annulled, or ended.

Please provide any added comments or limits to the previous section. (For example, you may name

people you would or would not want to be involved in decisions on your behalf. You may also specify

choices you would not want your agent to make.) Attach extra pages as needed.

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

Part 2. My Values

I want my agent and loved ones to know what matters most to me, so that they can make choices about

my health care that match who I am and what is of great value to me.

To give you a sense of what matters most to me, I’d like to tell you some things about myself, such as

how I enjoy spending my time, whom I like to be with, and what I like to do. I’d also like to tell you about

the circumstances that would make life no longer worthwhile for me.

1. If I were having a really good day, I would be doing the following:

2. What matters most to me is:

3. Life would no longer be worth living if I were not able to:

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

Part 3. My Health Care Instructions: My Choices, My Care

In the situation below, we ask you to think about a sudden unexpected event. You will always speak for

yourself if you are able; in the situations below, think about what you would want if you are not able to

speak for yourself.

If I become not able to communicate or make my own choices, I ask that my health care agent represent

my choices as detailed below and that my doctors and health care team honor them. If my health care

agent or alternate agents are not available or are not able to make choices on my behalf, this document

speaks for my wishes.

Note: If you choose not to give written instructions, your health care agent will make choices based on

your spoken wishes. If your wishes are unknown, your agent will make decisions based on what he or she

believes is in your best interest, thinking about your values.

1. Care to prolong life

Keep in mind these situations:

You have a sudden accident or stroke.

Doctors have determined you have a brain injury, leaving you not able to recognize yourself or your

loved ones. The doctors have told your agent and/or family that you are not expected to recover

these abilities. Life-sustaining treatments, such as a ventilator (i.e., breathing machine) or a feeding

tube are needed to keep you alive. In this condition, what would you want?

I would want to be kept comfortable and:

{



I would want to STOP life-sustaining treatments. I realize this would likely lead me to

choose

die sooner than if I were to continue care that is keeping me alive.

one

 I would want life-sustaining treatments to continue as long as possible.

Please give any extra instructions about life-sustaining treatments. For example, you may want to state a

specic time span that you would want to be kept alive if there were no change to your health.

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

2. CPR (Cardiopulmonary Resuscitation)

CPR tries to bring you back to life when your heart and breathing have stopped. It may involve chest

compressions (forceful pushing on the chest to make the heart contract), medicines, electrical

shocks, and a breathing tube.

You have a choice about CPR. CPR can save lives. It is not as useful as most people think. CPR works

best if done quickly, within a few minutes, on a healthy adult. When CPR is performed, it can result

in broken ribs, punctured lungs, or brain damage from lack of oxygen.* if you would like more

information about CPR, please ask for the brochure called CPR: My Choice.

If your heart and breathing stop, what would you want?



I always want CPR attempted.

choose

one

 I never want CPR attempted, but rather, want to permit a natural death.

†

{

 I want CPR attempted unless the doctor treating me decides any of the following:

• I have an incurable illness or injury and am dying, OR

• I have no reasonable chance of living if my heart or breathing stops, OR

• I have little chance of living if my heart or breathing stops and the process of

CPR would cause major pain.

* Research shows that if you are in a hospital and get CPR, you have a 22% chance of it working and you leaving the

hospital alive.

Ehlenbach, W., Barnato, A. E., Curtis, J. R., et al (2009). Epidemiologic study of in-hospital cardiopulmonary

resuscitation in the elderly. New England Journal of Medicine, 361:22-31. Girotra, S., Brahmajee K., Nallamothu, M.D.,

et al (2012). Trends in survival after cardiac arrest. New England Journal of Medicine, 167:1912-20.

† If you are certain you do not want CPR,

please present other documents you may want to ll out with your doctor.

Document type: Advance directive

(phone number) ______________________________________________. I would like my agent to tell them if

I am seriously ill or dying. I would like to include in my funeral, if possible, the following (people, music,

rituals, etc.):

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

Part 4. My Hopes and Wishes (Optional)

1. My thoughts and feelings about where I would prefer to die:

2. I want my loved ones to know that if I am nearing my death, I would appreciate the following

for comfort and support (prayers, rituals, music, etc.):

3. Religious or spiritual afliation:

I am of the __________________________ faith, and am a member of (faith/spiritual group)

____________

_________________________________ in (city) _________________________

________________

___________,

4. Other wishes/instructions:

Organ donation

If you considered donating organs when you die, you can declare your donor status when getting or

renewing a driver’s license or by registering through the donor registry found at

http://www.donatelifemaryland.org/.

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

Part 5. Making This Document Legally Valid

To make your advance health care directive legally valid in Maryland, it must be signed by two adult

witnesses:

Two Witnesses

1. Witnesses cannot be your health care agent, and at least one witness cannot have the right to any

nancial benet upon your death.

2. When you are with your witnesses, sign or acknowledge your signature.

3. Witnesses will sign on page 9.

4. You will sign below.

MY SIGNATURE

Print Full Name: ___________________________________________________________________________

Signature: _____________________________________________________ Date:

____________________

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

STATEMENT OF WITNESSES:

I declare under penalty of perjury under the laws of Maryland:

1. That the person who signed or acknowledged this advance health care directive is personally

known to me or that the individual’s identity was proven to me by convincing proof,

2. That the person signed or acknowledged this advance health care directive in my presence,

3. That the person appears to be of sound mind and under no threat, fraud, or undue inuence, and

4. That I am not appointed as an agent by this advance health care directive.

Witness Number One:

Print full name:

__________________________________________________________________________

Address:

________________________________________________________________________________

Signature: ______________________________________________________ Date:

___________________

Witness Number Two:

Print full name:

__________________________________________________________________________

Address:

________________________________________________________________________________

Signature: ______________________________________________________ Date:

___________________

At least one witness must not be entitled to proceeds of the individual’s estate or any nancial

benet upon the individual’s death. If you are not entitled to proceeds of the individual’s estate,

initial this line ______________________.

Document type: Advance directive

LIFE CARE planning

my values, my choices, my care

Full name: _________________________________

Medical record number: ____________________

Part 6. Next Steps

Now that you have lled out your advance health care directive, you should also take the following steps.

Discuss:

1. Review your health care wishes with the person you have asked to be your agent (if you haven’t

done so). Make sure he or she feels able to do this important job for you in the future.

2. Talk to the rest of your family and close friends who might be involved if you have a serious illness

or injury. Make sure they know who your health care agent is and what your wishes are.

Give copies:

1. Give your health care agent a copy of your advance health care directive.

2. Give a copy of your advance health care directive to your doctor or your local Kaiser Permanente

Medical Records Department.

3. Make a copy for yourself and keep it where it can be easily found.

Take with you:

1. If you go to a hospital or nursing home, take a copy of your advance health care directive and ask

that it be placed in your health record.

2. Take a copy with you any time you will be away from home for a long period of time.

Review often:

1. Review your health care wishes when any of the “Five D’s” occur:

Decade — when you start each new decade of your life

Death — when you go through the death of a loved one

Divorce — when you go through a divorce or other major family change

Diagnosis — when you are diagnosed with a serious health condition

Decline — when you feel a major drop or deterioration of an existing health condition,

especially when you are not able to live on your own

Changing your advance health care directive:

If your wishes change, ll out a new advance health care directive, tell your agent and your family, and

give a copy to Kaiser Permanente.

Copies of this document have been given to:

• Primary (main) health care agent Full name:______________________ Telephone:_____________

• Alternate health care agent #1 Full name:______________________ Telephone:_____________

• Alternate health care agent #2 Full name:______________________ Telephone:_____________

• Health care provider/clinic Name:_____________

___

_________ Telephone:_____________

• Others: Name:_______

________________ Telephone:_____________

LIFE CARE planning

my values, my choices, my care

Need additional assistance?

kp.org/lifecareplan

kp.org

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2101 E. Jefferson St., Rockville, MD 20852