This government document is issued by Department of Aging for use in Maryland
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https://www.google.com/url?client=internal-element-cse&cx=007821330218074952993:dlfjfzeuk3y&q=https://aging.maryland.gov/Documents/MakingHealthCareDecisionsforOthers2015.pdf&sa=U&ved=2ahUKEwjtmM-It5vxAhUhPewKHSelAT84ChAWMAh6BAgEEAE&usg=AOvVaw0IxpFLNxdCUp2rQU1IH225