2948                                          LAWS OF MARYLAND                                      Ch. 620

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 AND WILL OCCUR 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WITHDRAWN, AND THAT I BE PERMITTED TO DIE NATURALLY WITH ONLY THE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, THE ADMINISTRATION OF FOOD AND
WATER, AND THE PERFORMANCE OF ANY MEDICAL PROCEDURE THAT IS
NECESSARY TO PROVIDE COMFORT CARE OR 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 RIGHT TO CONTROL MY MEDICAL CARE AND
TREATMENT.

DECLARATION MADE THIS _____ DAY OF___________ (MONTH,

YEAR). I, _______________________, BEING OF SOUND MIND,

WILLFULLY AND VOLUNTARILY DIRECT THAT MY DYING SHALL NOT BE
ARTIFICIALLY PROLONGED UNDER THE CIRCUMSTANCES SET FORTH BELOW
AND DO HEREBY DECLARE IN THIS DECLARATION:

IF AT ANY TIME I AM TERMINALLY ILL, UNABLE TO PARTICIPATE
MEANINGFULLY IN DECISIONS REGARDING MY MEDICAL CARE AND TREATMENT
AND EXPECTED TO REMAIN SO, AND HAVE BEEN SO CERTIFIED BY 2
PHYSICIANS, 1 OF WHOM IS MY ATTENDING PHYSICIAN, AND BOTH OF WHOM

HAVE ALSO CERTIFIED THAT WITH OR WITHOUT LIFE SUSTAINING

PROCEDURES, I CANNOT RECOVER AND THAT, WITHOUT LIFE SUSTAINING
PROCEDURES, MY DEATH IS IMMINENT, I DIRECT THAT THESE PROCEDURES
BE WITHHELD OR WITHDRAWN AND THAT I BE PERMITTED TO DIE NATURALLY

WITH ONLY THE ADMINISTRATION OF FOOD AND WATER AND SUCH

MEDICATION AND MEDICAL PROCEDURES AS ARE NECESSARY TO PROVIDE ME
WITH COMFORT CARE AND TO ALLEVIATE PAIN.

THIS DECLARATION SHALL BE REGARDED BY MY FAMILY AND

PHYSICIAN(S) AS THE FINAL EXPRESSION OF MY INTENTION AND DESIRE
TO REFUSE LIFE SUSTAINING PROCEDURES AND ACCEPT THE CONSEQUENCES
OF THIS REFUSAL.

I AM AN ADULT OF SOUND MIND AND OTHERWISE 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