Declaration as Provided by Maryland Health-General Code Section 5-602
DECLARATION
On this _________________ day of ___________, I ________ ______, being of sound mind, willfully and voluntarily direct that my dying shall not be artificially prolonged under the circumstances set forth in this declaration:
If at any time I should have an incurable injury, disease, or illness certified to be a terminal condition by two (2) physicians who have personally examined me, one (1) of whom shall be my attending physician, and the physicians have determined that my death is imminent whether or not life-sustaining procedures are utilized and where the application of such procedures would serve only to artificially prolong the dying process, I direct that such procedures be withheld or withdrawn, and that I be permitted to die naturally with only the administration of medication, and the administration of food and water, and the performance of any medical procedure that is necessary to provide comfort care or to alleviate pain. In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention that this declaration shall be honored by my family and physician(s) as the final expression of my legal right to control my medical care or treatment. I am legally competent to make this declaration, and I understand its full import.
Signed _________________________________________________________
Address: _______________________________________________________
Under penalty of perjury, we state that this declaration was signed by ______________ in the presence of the undersigned who, at ______________’s request, in ______________’s presence, and in the presence of each other, have hereunto signed our names as witnesses this _______________ day of ___________________ 20_______. Further, each of us, individually, states that:
The Declarant is known to me, and I believe the Declarant to be of sound mind. I did not sign the Declarant’s signature to this declaration. Based upon information and belief, I am not related to the Declarant by blood or marriage, a creditor of the Declarant, entitled to any portion of the estate of the Declarant under any existing testamentary instrument of the Declarant, entitled to any financial benefit by reason of the death of the Declarant, financially or otherwise responsible for the Declarant’s medical care, nor the employee of any such person or institution.
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Address:
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Address:
Declaration as Provided by Maryland Health-General Code Section 5-602
Review List
This review list is provided to inform you about this document in question and assist you in its preparation. This simple Life Sustaining Declaration is valid in Maryland. Check with a local hospital or doctor’s office, as well as with an experienced medical attorney, to assure yourself of its compliance with current statute (s) in your state.
- Make multiple copies. Give one to your doctor (s), the local hospital, and have others available through your attorney and family. Remember, these kinds of documents are needed in emergency situations at worst and under stressful circumstances at best. So be sure they are available to the appropriate people easily, when needed.
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