 | Maryland Medical Power of Attorney Form |
The Maryland Medical Power of Attorney Form is comprised of two parts. Part I will name the Agent or Agents the Principal has chosen to assume the responsibility of being a Health Care Agent or Health Care Proxy to the Principal. Then, Part II, will allow the Principals to define their wishes should a situation render them unable or even incapable of making decisions regarding such issues as Health Care, Treatment, and Medical Interventions. There will be an additional form here, “After My Death,” where the Principal may choose a party to assume decision making authority over his or her remains, organ donations, funeral arrangements, etc. or specifically define his or her wishes. This document should be strongly considered by all Signature Parties as it will carry some serious implications and responsibilities. When it has been completed and signed (ideally Notarized), multiple copies should be made to dispense to all affected parties (Principal, Agent, Insurance Company, Hospital, Personal Physician, etc.). The Principal should keep a record of where it has been dispensed and may choose to revoke this document at any time so long as he or she is mentally capable of doing so.
How To Write
1 – Obtain the Maryland Medical Power of Attorney
Select the link on this page then, download the form. There will be some valuable information in the first few pages that should be read and comprehended by all parties involved.
2 – Principal Name and Date of Birth
Locate the first page of the form. On the first blank space following the title box “Maryland Advance Directive: Planning For Future Health Care Decisions,”
- Print the Full Name of the Principal.
- Next, on the blank line labeled “Date of Birth,” report the Birth Day of the Principal by reporting the Month, Day, and Year when he or she was born
3 – Naming the Maryland Primary Agent’s Information
If the Principal requires Part I to be reported, then enter the Full Name of the Primary Agent in Part I, Section A, “Selection of Primary Agent” on the blank line labeled “Name.”
- On the blank lines labeled “Address,” document the Primary Agent’s Physical Address. This should be the Building Number, Street, Apartment Number, City, State, and Zip Code where the Primary Agent will be physically found.
- Report all the Telephone Numbers where the Primary Agent can be reliably reached. This section at a minimum should contain the Primary Agent’s Home Phone Number. In addition to this, if possible, report the Home Number, Cell Number, and Work Number of the Primary Agent.
4 – The Back-Up Agent Option
Part I, Section B, “Selection of Back-Up Agents,” is optional and will only be required if the Principal wishes to have the additional insurance of Naming a Secondary Agent should the Primary Agent be unavailable or unable to live up to his or her responsibilities.
- Item 1 in Section B will require three pieces of information: the Back-Up Agent’s Full Name, Address, and Telephone Numbers. To begin, enter the Full Name of the Back-Up Agent on the first blank line.
- Then on the second blank line, report the Complete Physical Address where the Back-Up Agent is located.
- Finally, on the last blank line, enter the Home Phone Number, Work Number, and Cell Number where the Back-Up Agent may be reached.
Item 2 of this Section will also provide the space needed for a second Back-Up Agent’s Information to be documented. This party will act in carrying out the Principal’s Interests should the Primary and First Back-Up Agent cannot reliably fulfill their responsibilities.
- The first line, labeled “Name,” requires the Name of the Second Back-Up Agent entered.
- The second and third lines have been provided so the Second Back-Up Agent’s Complete Address may be documented.
- Finally, report the Home, Cell, and Work Telephone Numbers maintained by the Second Back-Up Agent on the blank line labeled “Telephone Numbers.”
5 – Powers of the Maryland Health Care Agent
Section C, in Part I, will define the powers the Health Care Agent may assume regarding the Medical Treatment and Health Care Decisions of the Principal. This should be read carefully by all parties involved. At the end of the points defined will be a text box where the Principal may list any conditions, limitations, or considerations that should apply to the Primary and Back-Up Agents’ powers. This text box is optional, however for the sake of security, the Principal may put a big “X” in it if no such concerns exist.
6 – Entities Available for Agent Consultation
The Principal may wish his or her Primary Agent to consult with certain parties (such as family members) if faced with a difficult decision. The Principal may list these individuals in Section E of Part I, “People My Agent Should Consult.” Two columns will be provided (each with four lines): “Name(s)” and “Telephone Number(s).” Report the Name and Telephone Numbers of One to Four people the Agent may consult utilizing this area. This area is optional.
7 – Optional Pregnancy Directive
In some cases, the Principal may be a Woman who may wish to protect her interests in case she is pregnant and rendered medically unable to communicate her health care preferences. The text box in Section F, “In Case of Pregnancy,” will provide the option of conveying the Principal’s concern in this matter. List any such directives for the Agent in this box.
8 – When Should The Maryland Health Care Agent Seize Authority
The Agent will need instructions on when he or she will be expected to step up on behalf of the Principal’s interests. This will be reported in Section H, “Effectiveness of this Part.”
- If the Principal wishes the Agent’s Power to go into effect upon the Principal’s Signature at the request of the Principal or in the event the Principal is medically unable to represent him or herself, the Principal must Initial the blank line in Item 1.
- If the Principal wishes this power only to go in effect upon a Physician’s determination the Principal is unable to make Medical Decisions, then Item 2 must bear the Principal Initials on the blank line provided. Only one of these items may be initialed.
9 – Defining the Maryland Living Will
Locate Section A (“Statement of Goals and Values”) below the title box “Part II: Treatment Preferences (Living Will).” The Principal’s personal decisions/concerns/values should be reported in this area This should be a specific report on what the Principal considers the Agent to keep in mind (and adhere to) when the Principal is in the final part of his or her life.
10 – When the Principal has a Terminal Condition
Section B, in Part II, will provide three statements the Principal may choose from to define his or her desires if death becomes a certainty with or without treatment. The Principal may choose either one of these definitions or none of them (cross out this section if none are required).
- If the Principal only to be made comfortable for a Natural Death by declining medical interventions (including fluids and nutrition) then he or she should initial the blank line in Item 1.
- If the Principal does not wish for any medical interventions outside of arrangements for his or her comfort and nourishment when a Natural Death is imminent, the Principal should Initial Item 2.
- If the Principal wishes that death be delayed through any means necessary (including nutrition and fluids) then he or she must Initial Item 3.
11 – When The Principal Is In a Persistent Vegetative State
A Persistent Vegetative State will be defined as being permanently unconscious, lacking self-awareness, and unaware of one’s surroundings. Section C, “Preferences In Case of Persistent Vegetative State,” will allow the Principal to define his or her wishes should one have such a diagnosis. Three choices will be provided for the Principal. If this section is filled out, the Principal must select one statement by Initialing the blank line to the right of the appropriate choice. This section is optional. If the Principal does not wish to make this choice here, he or she must simply cross out this section.
- Item 1 should be Initialed if the Principal wishes to be kept comfortable until a natural death occurs. That means no medical interventions will be allowed to extend life including receiving nourishment or fluids.
- Item 2 should be Initialed if the Principal wishes a Natural Death without medical interventions but, wishes to be maintained medically including receiving nourishment and fluids
- Item 3 should be Initialed if the Principal wishes to prolong his or her life for as long as possible even if nourishment and other intravenous fluids must be supplied.
12 – When the Principal Is In An End-Stage Condition
In Section D, “Preference In Case Of End-Stage Condition,” where the Principal has an incurable condition that has rendered him or her incapable of self-care and dependent, three choices have been provided for the Principal to define his or her wishes. The Principal may choose one Item or cross out the section.
- If the Principal only wishes to be made comfortable so that a Natural Death may occur, then he or she must Initial Item 1. This choice means the Principal will not receive any life extending procedures, medical interventions, nourishment, or fluids.
- If the Principal wishes to be kept comfortable and allow a Natural Death but also be provided nourishment and fluids, then he or she must Initial Item 2. This choice will not allow for any life extending or saving procedures to be performed.
- If the Principal wishes to extend his or her life through any means necessary (including nourishment and fluids) then he or she must Initial Item 3.
13 – Life Sustaining Procedures and Pregnancy
Women, who are in the child bearing years, may indicate specific directives or instructions in the event they are pregnant and unable to represent themselves due to a medical condition such as being in a Permanent Vegetative State utilizing the text box in Section E, “In Case of Pregnancy.” The Principal must make an effort to be very clear regarding what her wishes are if she is pregnant and medically unable to make a decision or respond.
14 – Agent Flexibility
Locate Section G, “Effect of Stated Preferences.” This section provides the Principal with the chance to either give the Agent flexibility in Decision Making or not.
- If the Principal will allow the Agent flexibility in the decision making procedure, the Principal will need to Initial Item 1.
- If the Principal will not allow any deviations from his or her instructions regardless of the circumstances, the Principal would need to Initial the blank line Item 2.
15 – Declarant Signature
The Principal will need to read the paragraph on the page titled “Part III: Signature and Witnesses,” then Sign his or her Name on the blank line labeled “Signature of Declarant.” On the line adjacent to this, the Signature Date must be reported. Below the Principal Signature will be a paragraph which all Signature Witnesses should read. There will be enough room for two Witnesses to Sign their Names, provide their Addresses, and supply the Signature Date at the time they observe the Principal Signing this document.
15 – After the Death of the Principal
Locate the box labeled “After My Death.” This form has been included with the Medical Power of Attorney, since the Principal may have some preferences as to how he or she wishes the remains to be handled. This is an optional form. To begin locate the box labeled with the words “After My Death.” On the blank line below this, next to the word “By,” the Printed Name of the Principal should be displayed. Next to this on the line labeled “Date of Birth,” this individual’s Birth Date must be supplied.
16 – Defining Organ Donation
If the Principal wishes to donate organs, tissues, or other parts of his or her body, then “Part I: Organ Donation” will allow for this information to be documented. The Principal must Initial all statements that coincide with his or her wishes or cross out the statements that do not apply.
To begin, locate the words “Upon my death I wish to donate.” If the Principal wishes to be an Organ/Tissue Donor, the corresponding blank space must bear his or her initials.
- If the Principal wishes to donate any needed parts of his or her body, the blank line corresponding with the statement “Any needed organs, tissues, or eyes” must be Initialed by the Principal
- If the Principal will only donate certain parts of his or her body, then these parts may be defined in the text box below the statement “Only the following organs, tissues or eyes”
- Next, the Principal may decide for what use his or her donation may be put to use. This will come in the form of a list where the Principal must Initial the items defining acceptable reasons for the use of his or her donation: For Transplantation, For Therapy, For Research, For Medical Education, and/or For Any Purpose Authorized By Law.
- If the Principal wishes for his or her body to be donated to a Medical Study Program, then he or she must Initial the blank space under the box with the words “Part II: Donation of Body.”
17 – The Principal Remains and Funeral Arrangements
The Principal may define how to handle his or her own remains in “Part III: Disposition of Body and Funeral Arrangement.” Locate the box with this heading on the page after the Signature Page.
- If the Principal wishes the Health Care Agent Named in the Advance Directive to decide how to handle the Principal’s remains and funeral arrangements then locate the statement beginning with “The health care agent…” The Principal will need to Initial the blank space corresponding to this statement.
- If the Principal has a specific person in mind for this task, then locate the word “OR” in bold and enter the Name of this individual on the blank line below the words “This person.” This must be followed with the Address and the Telephone Number of this individual
Below this will be a text box. Here, the Principal may choose to define what precisely his or her wishes are. If there is anything regarding the handling of his or her remains and funeral arrangements written in this box, the individual charged with carrying out these arrangements will be expected to follow the Principal’s Instructions.
16 – Verifying Principal Consent to Funeral Arrangements
Locate the box with the words “Part IV: Signature and Witnesses.” Here, the Signature of the Principal should be provided on the blank line labeled “Signature of Donor.” The next blank space on this line will require the Date the Principal Signed this document. The next area will concern itself with the Witnesses who are present at the time the Principal Signs this document. There will be two columns. Each Principal should Sign his or her Name in the column on the left then provide a Signature Date in the corresponding space in the column on the right.
