"Advance Directive for Health Care" - Maine

A Maine Advance Directive for Health Care is a set of instructions about preferred medical care that takes effect when a patient becomes unable to make decisions. In addition to listing preferences for medical care, the form provides individuals with the option of appointing a health care proxy. A health care proxy - otherwise known as a health care agent or surrogate - is a person who has the authority to make health-related decisions on another person's behalf.

Make your own Advance Directive with our form builder or download a pre-made form through the link below.

If an individual has never had an Advance Directive made, any health care decisions may be made for them by a court-appointed guardian (a spouse, an adult child, an adult sibling, an adult relative or a professional). The document is regulated by Title 18-A Article 5 (Protection of Persons Under Disability and Their Property) of the Probate Code. The declaration must be in writing and signed two (2) witnesses.

There is a difference between this form and a Living Will in Maine. A Living Will is a specific type of an Advance Directive for Health Care that becomes effective only in the event of a terminal illness.

ADVERTISEMENT

Download "Advance Directive for Health Care" - Maine

206 times
Rate
(4.5 / 5) 10 votes
Maine Advance Directive for Health Care
Section I - Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and intentionally, by this Living Will, direct my family,
physician(s), attorney, and any other individuals who may become responsible for my
health and well-being in the future, whether partly or fully, to take the following
actions in each of the circumstances described in the Living Will below.
1. In the event that I develop a condition considered “terminal” with my attending
physician and one other medical professional both agreeing that there is no
chance for improvement, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. In the event that I fall into a coma with my attending physician and one other
medical professional both agreeing that there is no chance for recovery, I direct
the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. In the event that I develop a persistent vegetative state with my attending
physician and one other medical professional both determining that there is no
chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Maine Advance Directive for Health Care
Section I - Living Will
I, _______________________________ with a mailing address of ______________
____________________________________________________________________,
being of sound mind, memory, disposition, understanding, and at least eighteen years
of age, do willfully and intentionally, by this Living Will, direct my family,
physician(s), attorney, and any other individuals who may become responsible for my
health and well-being in the future, whether partly or fully, to take the following
actions in each of the circumstances described in the Living Will below.
1. In the event that I develop a condition considered “terminal” with my attending
physician and one other medical professional both agreeing that there is no
chance for improvement, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. In the event that I fall into a coma with my attending physician and one other
medical professional both agreeing that there is no chance for recovery, I direct
the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. In the event that I develop a persistent vegetative state with my attending
physician and one other medical professional both determining that there is no
chance for recovery, I request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4. In addition to the directions I have listed above, I also request the following:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Section II - Health Care Proxy
I would like to appoint __________________________________ with a mailing
address of ____________________________________________________________,
to act as my Health Care Proxy. I have talked with this person about my wishes.
They can be reached at ______________________________ during daytime hours or
at ______________________________​
a t night.
If this person is not able or not willing to serve as my Health Care Proxy, I would like
to appoint __________________________________ with a mailing address of
____________________________________________________________, to act as
my Health Care Proxy. I have talked with this person about my wishes.
They can be reached at ______________________________ during daytime hours or
at ______________________________​
a t night.
I want my Health Care Proxy:
❏ to follow only the directions as listed on this form.
❏ to follow my directions as listed on this form and to make any decisions about
things I have not covered in the form.
❏ to make the final decision, even though it could mean doing something
different from what I have listed on this form.
Section III - Acknowledgement
I understand the following:
If my doctor or hospital refuse to follow the directions I have listed, they must
see that I get to a doctor or hospital who will follow my wishes.
If I am pregnant, or if I become pregnant, the choices I have made on this form
will not be followed until after the birth of the child.
● If the time comes for me to stop receiving life-sustaining treatment or food and
water through a tube or an IV, I direct that my doctor talks about the good and
bad points of doing this, along with my wishes, with my health care proxy, if I
have one.
Section IV - Signatures
Principal
By signing this Advance Directive in front of the witnesses identified below, I hereby
administer and subscribe to the declarations made above both freely and voluntarily,
and wholeheartedly request that my family, physician(s), attorney, and any other
individuals who may in the future become responsible for my health and well-being,
whether partly or fully, all abide by my wishes as stated herein.
_________________________________
Name
_________________________________
Signature
_________________________________
Date of signing
Witnesses
This Advance Directive was signed by _________________________________ in the
presence of the following two witnesses, who by their signatures below, confirm that
_________________________________ was, at the time this document was signed,
at least eighteen years of age, of sound mind, memory, disposition, understanding, not
under any improper influence and able to understand the weight of this decision. The
undersigned have subscribed this document in the presence of each other and
_________________________________ and at their request.
First Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Second Witness: ​ _ ________________________________ ​ w ith a mailing address of
____________________________________________________________________.
_________________________________
Signature
_________________________________
Date of signing
Health Care Proxy
I, _________________________________, am willing to serve as the health care
proxy.
_________________________________
Signature
_________________________________
Date of signing
I, _________________________________, am willing to serve as the health care
proxy if the other health care proxy will be unable to serve.
_________________________________
Signature
_________________________________
Date of signing
Notary Acknowledgement
STATE OF MAINE
COUNTY OF _________________________________
I, _________________________________, a Notary Public of said County, do certify
that _________________________________, as Principal, and __________________
________________ and _________________________________, as witnesses,
whose names are signed to the writing above bearing date on the _______ day of
______________, ______, have this day acknowledged the same before me.
Given under my hand this _______ day of ______________, ______.
My commission expires: ___________________________________
______________________________________
Signature of Notary Public
ADVERTISEMENT

What Is a Maine Advance Directive?

An Advance Directive is a document in which an individual states their preferences regarding health care procedures that become effective when they are no longer able to make decisions for themselves. The contents can be updated and changed as often as the individual wishes.

The form includes two parts in total:

  1. A Living Will - a specific type of Advance Directive which can also be used on its own - is a signed and witnessed document called a "declaration" or "directive" with instructions for an attending physician to withhold or withdraw certain medical interventions once the signer is no longer able to verbally make decisions about medical treatment.
  2. A Durable Power of Attorney for Health Care is a notarized document in which the signer designates an agent to make health-related decisions on their behalf.

How to Write an Advance Directive in Maine?

  1. Decide on whether you want to include a Living Will in your advance health care instructions.
  2. If you decided to include a Living Will be specific about such things as CPR, breathing machines, antibiotics, kidney dialysis, tube-feeding, and certain surgical procedures that you are willing to authorize.
  3. Discuss your decisions with your partner or spouse, your doctor, and your attorney.
  4. Elect a decision-maker - a health care proxy or agent. Choose someone you believe will be able to follow your wishes whatever those may be. This will help ensure that your wishes are carried out correctly and in full.
  5. Give a copy of the document to your health care proxy and ask for it to be kept in a safe place. Keep the original in an easy-to-find place. Do not lock it in a safe-deposit box or filing cabinet that only you can access.
Page of 5