The Maine Health Care Advance Directive Form is a crucial document that allows individuals to express their preferences regarding medical care in the event they are unable to communicate these wishes personally in the future. It encompasses decisions ranging from appointing a healthcare agent to specifying desires about certain medical treatments and end-of-life care. Understanding the components and importance of this form can empower individuals to make informed decisions about their healthcare. For those ready to take control of their medical future, click the button below to fill out the form.
Making decisions about your healthcare in advance is a thoughtful and responsible step towards ensuring that your wishes are respected, even when you can no longer communicate them yourself. The Maine Health Care Advance Directive Form provides a comprehensive and legally recognized way for individuals to outline their preferences and instructions for future medical care. This detailed form covers several critical aspects, beginning with the appointment of a healthcare agent in Part 1, who is empowered to make decisions on your behalf if you become incapacitated. It also allows you to specify your wishes regarding specific treatments in Part 2, nominate a primary physician in Part 3, decide on organ and tissue donation in Part 4, and outline your preferences for funeral and burial arrangements in Part 5. The importance of signing and dating the directive in Part 6, along with having witnesses, emphasizes the form's legal aspect and the need for clear communication with healthcare providers, family, and other relevant parties. Furthermore, Part 7 addresses the Do Not Resuscitate (DNR) orders, offering an option for those who do not want to be revived under certain conditions. The form's flexibility to change almost any part, except for the signature and DNR sections, and the encouragement to discuss your decisions with loved ones and professionals highlight the emphasis on personal choice, informed consent, and open dialogue in healthcare planning.
Maine Health Care
Advance Directive Form
You may use this form now to tell your physician and others what medical care you want to receive if you become too sick in the future to tell them what you want. You may choose to fill out the whole form or any part of the form and then sign and date the form in Part 6. These are the parts:
Part 1
Fill this out if you want to choose someone to make all your health care decisions for you,
either right away or if you become too sick to tell others what you want. This person is
called your agent.
Part 2
Fill this out if: (1) you did not name an agent in Part 1 and now want to choose whether
you want certain treatments or, (2) you did name an agent in Part 1 and want to tell your
agent your wishes about certain treatments, knowing that your agent must follow your
directions.
Part 3
Fill this out if you want to give the name of your primary physician, physician assistant or
nurse practitioner.
Part 4
Fill this out if you want to make decisions about donating your organs, body or tissues
after your death.
Part 5
Fill this out if you want: (1) to choose someone to make all funeral and burial decisions
after your death, or (2) to tell your family any wishes you have about funeral and burial
decisions.
Part 6
You must sign and date your Advance Directive form on this page. Have two witnesses
sign the form at the same time you sign it. Tell others about your decisions and give
copies to your physician, other health care providers, family and hospital.
Part 7
If you do not wish to be revived by ambulance crews should your heart or breathing stop,
then you and your physician (or nurse practitioner or physician assistant) need to sign this
Do Not Resuscitate (DNR) form.
Page 1 of 14 Revised February 2008
Note
You may change any part of this form except for Part 6 and Part 7. You may cross out any words, sentences, or paragraphs you do not want. You can also add your own words. If you make any changes to the form, it is best if you put your initials and the date next to each change so that everyone knows it was your decision to make the change. The form lets you choose different ways to handle your care by checking boxes or filling in blanks. You may initial each box and each blank you fill in to show that it was your decision to check the box or fill in the blank.
Before filling out this form, we suggest that you talk with your lawyer, family members, physicians, and others close to you about your wishes. If you make changes or complete a new form, be sure to let everyone know.
My Name (please print)______________________________________________________
My Address _______________________________________________________________
My Birth date______________________________________________________________
This is a list of all the people who have copies of my signed health care advance directive:
1. ________________________________________________________________________
2.________________________________________________________________________
3.________________________________________________________________________
4. ________________________________________________________________________
5. ________________________________________________________________________
6. ________________________________________________________________________
7. ________________________________________________________________________
8. ________________________________________________________________________
9. ________________________________________________________________________
10. ________________________________________________________________________
Page 2 of 14
Revised February 2008
Part 1 – Power of Attorney for Health Care
Instructions:
This part lets you choose another person to make health care decisions for you, either right away or when you are too sick to choose your own care. The person you choose is called your agent. You may also name a second and third choice to be your agent, if your first choice is not willing, reasonably available or able to make decisions for you. If you choose an agent on this form, but do not fill out any other parts of the form, your agent will be able to:
•Make all health care decisions for you, including decisions regarding tests, surgery and medication;
•Decide whether or not to have food or fluids given to you through tubes or fed into your veins through an IV;
•Decide whether or not to use treatments or machines to keep you alive or to restart your heart or breathing;
•Choose who will give you health care and where you will get it, such as hospitals, nursing homes, assisted living settings, home health, or hospice care; and
•Make any health decision he or she believes would be consistent with your values or in your best interest, even if it is not listed in the form.
Who can be your agent:
You can name any adult you trust to be your agent, except your agent may not be the owner, operator or employee of a nursing home or residential long-term care facility where you are receiving care, unless that person is your relative.
How your agent must make decisions:
If your agent does not know what you want, the agent must make decisions consistent with your personal values, if known, or based on your best interests. In Part 2, you can decide what you want in advance. If you make choices in Part 2, your agent must make decisions based on those choices.
Who can see your health care information:
Once your agent has the right to make health care decisions for you, your agent can look at your medical records and consent to giving your medical information to others. The state and federal privacy laws let your agent see all of your health information so that he or she can make the right decision for you.
The first part of your advance directive begins on the next page.
Page 3 of 14 Revised February 2008
YOUR ADVANCE DIRECTIVE BEGINS HERE
Choosing an agent: Fill in your name and the name of the person you choose to be your agent to make health care decisions for you here:
My name______________________________________________________________________________
My agent’s name________________________________________________________________________
Title or relationship to me_________________________________________________________________
My agent’s address______________________________________________________________________
My agent’s home phone (___)___________________ My agent’s work phone (___)__________________
If the agent I have named above is not willing, reasonably available or able to make decisions for me, I choose the following person to be my agent:
If the person I have named as Choice # 2 is not willing, reasonably available or able to make decisions for me, I choose the following person to be my agent:
Choice # 2 to be my agent
Choice # 3 to be my agent
Name____________________________________
Name_________________________________
Title or Relationship to me___________________
Title or Relationship to me________________
Address__________________________________
Address_______________________________
_________________________________________
______________________________________
Home Phone (___)__________________________
Home Phone (___)_______________________
Work Phone (___)__________________________
Work Phone (___)_______________________
You may change your mind later about who you want to be your agent. If you want to stop the agent you have named from making decisions for you, you must tell your primary physician or fill in these blanks:
I do not want ________________________ to be my agent. _______________________________________
My signature
Date you filled out and signed this section _________________________
Any time you cancel, replace or change this form you should give copies of the changed or new form to everyone who has a copy of your original form.
Page 4 of 14
Your agent’s power:
When your agent can start making decisions for you: (Check only one box: A or B)
A. My agent can make decisions only when my primary physician or a judge decides that I am too sick to make my own health care decisions.
OR
B. My agent can start making health care decisions for me right away, but this does not mean I have given up the right to make my own decisions if I am still able and willing to make my own decisions. When my agent makes a health care decision for me, I will be told, if possible, about that decision before it is carried out unless I say I do not want to know. If I disagree with that decision and am still able to decide, I can make a different decision. As long as I am able, I can end my agent’s right to make decisions for me, change my agent or make my own decisions. If I want to end my agent’s right to make decisions for me, I must tell my primary physician or put my decision in writing and sign it with the date of my signature.
Nominating a guardian:
A guardian is a person chosen by a court to make decisions about your personal care. These decisions can include not only health care, but other decisions such as where you will live and how your personal needs will be met. If you wish, you may ask that a court assign your agent as your guardian, if appointment of a guardian should become necessary. Check the box below to nominate your agent to be your guardian, if a judge needs to appoint a guardian for you.
I nominate my agent to be my guardian if a judge needs to appoint a guardian for me.
If you want to nominate someone other than your agent to be your guardian, you may fill in the section below.
If a judge needs to appoint a guardian for me, I nominate the person named below as my guardian:
Name__________________________________________ Title or Relationship to me________________
Address______________________________________________________________________________
_____________________________________________________________________________________
Home Phone (___)_______________________ Work Phone (___)______________________________
Page 5 of 14 Revised February 2008
Part 2 – Special Instructions
Instructions if you did not name an agent in Part 1:
If you did not name an agent in Part 1, you should fill out this Part to state what you want for care if you become too sick to make your choices known.
Instructions if you did name an agent in Part 1:
If you named an agent in Part 1, you do not have to fill out this part of the form. If you want your agent to make all of your health care decisions, DO NOT fill out this part of the form. Your agent will make decisions in your best interests, including decisions to refuse treatment. However, you may fill out this part if you want to give special directions to your agent about your wishes, such as when you are near death, in a permanent coma or no longer able to make your own decisions. You may also cross out or add words. It is best if you put your initials and date next to any changes you make so everyone knows the changes were your decision. If you complete this part, your physician and others will follow these instructions and your agent cannot make a different decision. You may also write your wishes on another piece of paper, sign it, date it, and keep it with this form.
Life-Sustaining Treatment Choices:
You may check one of the two boxes below to show your choice about getting treatments that would keep you alive:
Choice not to be kept alive
Choice to be kept alive
I do not want treatment to keep me alive if my
I want to be kept alive as long as possible
physician decides that either of the following is true;
within the limits of generally accepted health
(i) I have an illness that will not get better, cannot
care standards, even if my condition is
terminal or I am in a persistent vegetative
be cured, and will result in my death quite soon
state.
(sometimes referred to as a terminal condition),
(ii) I am no longer aware (unconscious) and it is very
likely that I will never be conscious again (sometimes
referred to as a persistent vegetative state).
Page 6 of 14
You may also check one of the two boxes below to show your choice about treatment that would keep you alive if, in the future, you have late stage Alzheimer’s disease or other severe dementia. These choices will not limit the authority under state law for your agent, surrogate, guardian or physician to make treatment choices if you are unable to make your own decisions and are not in late stage Alzheimer’s disease or other severe dementia.
If my physician and a second physician decide that I am in the late stage of Alzheimer’s disease* or other severe dementia, I do not want treatment to keep me alive.
I want treatment to keep me alive as long as possible within the limits of generally accepted health care standards, even if my physician and a second physician decide that I am in the late stage of Alzheimer’s disease or other severe dementia.
*Only a physician can determine that someone is in the late stage of Alzheimer’s disease. People in the late stages of Alzheimer’s disease generally have a number of the following characteristics: loss of the ability to respond to their environment; loss of the ability to speak; loss of the ability to control movement; loss of the capacity for recognizable speech, although words or phrases may occasionally be uttered; needing help with eating and toileting; general incontinence of urine; loss of the ability to walk without assistance, then the ability to sit without support, then the ability to smile, and the ability to hold their head up; reflexes become abnormal; muscles grow rigid; and swallowing is impaired.
Tube Feeding: You may check one of the two boxes below to show your choice about tube feeding or having water and nutrition fed into your body through an IV or tube (artificial nutrition and hydration):
Artificial nutrition and hydration should not be given, or should be stopped, based on the other life-sustaining treatment choices I made about keeping me alive on Pages 6 and 7.
Artificial nutrition and hydration should be given regardless of my condition.
Page 7 of 14 Revised February 2008
Relief from Pain: You may check the box or fill in the blanks below to show your choice about relief of pain or discomfort.
I want treatment for relief of pain or discomfort to be given at all times, even if it shortens the time until my death or makes me drowsy, unconscious or unable to do other things.
These are my wishes about relief of pain or discomfort:
Other Directions:
You may give more directions or add any other treatment choices in the space below:
Page 8 of 14 Revised February 2008
Part 3 — Primary Physician
This section is optional. Fill out this part only if you wish to name your primary physician today.
Name of my primary physician:__________________________________________________________
Address: _____________________________________________ Phone: ________________________
I want any agent I named in Part 1 to talk with this physician about my health care. If the physician I have named above is not willing, reasonably available or able to carry out my wishes, I want the agent I named in Part 1 to talk with the physician listed below:
Name of physician: _____________________________________________________________
Address:_____________________________________________ Phone:___________________
If you want your agent or those making decisions for you to speak with a nurse practitioner or physician assistant before making a decision, you may complete the following section:
Name of nurse practitioner or physician assistant: _____________________________________
Address: _____________________________________________ Phone:___________________
Page 9 of 14 Revised February 2008
Part 4 – Donation of Body,
Organs or Tissues at Death
This section is optional. Fill out this part only if you want to give directions about donating your body, organs or tissues after your death.
I do NOT wish to donate any organs, tissues or parts.
---------------------------------------------------------------------------------------------------------------------------------------
I have checked below my choices about donating my body, organs or tissues after death. I have spoken with my family so that they will not object to my wishes after I die.
I give my body. OR
I give any needed organs, tissues or parts. OR
I give only the following organs, tissues, or parts:
____________________________________________________________________
My gift is for the following purposes (you may check any number of boxes):
My gift is for transplant or therapy for another person, to be chosen based on generally accepted health care standards.
My gift is for research and education. My preference, if any, is to give my body, organs, or tissues to the following hospital, medical school, or physician:
Name ________________________________________________________
Address _______________________________________________________
________________________________________________________
I understand that I may need to contact the hospital, medical school, or physician before I die in order for them to accept my body, organs or tissues after my death.
Page 10 of 14 Revised February 2008
Filling out the Maine Health Care Advance Directive Form is an important step in planning for the future of your health care. This document allows you to communicate your health care preferences, including appointing someone to make decisions on your behalf if you're unable to do so yourself. It's crucial to carefully consider your choices and discuss them with your preferred contacts before filling out the form. Here's a straightforward guide to help you complete this form.
Keep in mind that your health care preferences and situation may change over time. It's a good idea to review and potentially update your Advance Directive periodically, especially after any significant health diagnosis, change in family status, or change in your health care preferences. When updating your form, be sure to communicate these changes to everyone involved.
The Maine Health Care Advance Directive form is designed to give individuals a way to communicate their health care preferences for a time when they might be unable to make or communicate those decisions themselves due to illness or incapacity. This form enables individuals to designate an agent to make health care decisions on their behalf and specify their wishes regarding treatments, organ donation, funeral, and burial arrangements. By filling out this form, a person can ensure that their health care choices are known and respected, even when they cannot communicate them directly.
To choose an agent for making health care decisions, you need to complete Part 1 of the Maine Health Care Advance Directive form. The chosen agent can be any adult you trust, excluding those who are owners, operators, or employees of the nursing home or residential long-term care facility providing your care, unless they are related to you. It’s important to discuss your health care preferences with your chosen agent ahead of time, ensuring they understand and are willing to act according to your wishes. You also have the option to name secondary agents if your primary choice is unavailable or unwilling to act when needed.
Yes, you are allowed to make changes to any part of your Maine Health Care Advance Directive form except for Part 6 (the signature and witness page) and Part 7 (Do Not Resuscitate form). If you decide to make changes, it’s recommended to initial and date next to each change to clearly document that these alterations were made by you. Additionally, after making changes, it's crucial to inform everyone who has a copy of your original directive, including your health care providers and family members, and provide them with updated copies to ensure your current wishes are known and followed.
By taking these steps, you can help ensure that your health care preferences are respected and followed.
Not naming an alternate agent: Many people fill out the Maine Advance Directive form but overlook the option to name a second or third choice for their health care agent. In situations where the primary agent is unavailable or unwilling to make decisions, having an alternate can ensure that the individual's health care decisions are still in trusted hands.
Leaving parts of the form blank: Some individuals only fill out specific sections and neglect others, not realizing that completing the entire form or at least reviewing every part is crucial for comprehensive advance care planning.
Failure to discuss choices with the agent: A common mistake is not having a detailed conversation with the chosen agent about one's health care preferences, leading to potential confusion or conflicts when the agent has to make decisions.
Not using specific medical treatments or conditions examples: When indicating preferences in Part 2, being too vague about desired treatments or medical conditions can lead to misinterpretation of the individual’s wishes.
Forgetting to sign and date Part 6: An unsigned or undated form is considered incomplete and will not be legally effective. Ensuring that Part 6 is properly signed and witnessed is essential.
Overlooking the necessity for witness signatures: Not having two witnesses sign the form at the same time as the individual can invalidate the entire directive. Witnesses play a crucial role in verifying the authenticity of the directive.
Not informing family members and physicians: After completing the form, failing to discuss it with family members and physicians is a mistake. This discussion is crucial for ensuring that everyone understands the individual's wishes.
Not providing copies to the right people: People often forget to distribute copies of the signed form to important parties, including health care agents, family members, and health care providers, which can lead to unnecessary confusion.
Thinking the form is irrevocable: Some people hesitate to complete the form under the misconception that it cannot be changed. It's important to note that the Maine Advance Directive form can be revised or revoked at any time to reflect new decisions or circumstances, except for Part 6 and Part 7.
Avoiding these common mistakes can help ensure that the Maine Health Care Advance Directive Form accurately reflects your wishes and can be effectively used when needed.
When preparing advance healthcare directives, it's essential to have a comprehensive understanding of the various forms and documents that can complement the Maine Advance Healthcare Directive Form. These documents serve different but complementary purposes, ensuring that an individual’s healthcare preferences are respected and followed.
To ensure one's healthcare wishes are fully understood and respected, it's advisable to have a discussion with legal and medical professionals about completing these documents. Each serves an essential role in guiding medical professionals and loved ones during critical healthcare decisions. It’s equally important to review these documents periodically and update them as one’s health status or preferences change.
The Maine Health Care Advance Directive Form shares similarities with a Medical Power of Attorney document. Both allow you to appoint an agent to make health care decisions on your behalf if you're unable to do so yourself. This agent has the authority to make decisions regarding treatments, hospital care, and other medical interventions according to your wishes or, if unknown, in your best interest.
Like a Living Will, Part 2 of the Maine Advance Directive lets you outline specific medical treatments you do or do not want. This part ensures your health care preferences are known, such as whether you wish to receive life-sustaining treatments, mirroring the purpose of a Living Will in stating your decisions regarding end-of-life care.
The document also resembles a Designation of Health Care Surrogate form in Part 1, where you can designate someone to make health decisions for you. This is similar to naming a health care surrogate or proxy, who will have the authority to speak with healthcare providers and make decisions on your behalf based on your stated wishes or, if not stated, what they believe to be in your best interest.
In Part 3, where you can name your primary physician, the form acts similarly to a Physician Orders for Life-Sustaining Treatment (POLST). While the POLST is more specific about medical treatments in serious health conditions, both documents serve to communicate your health care preferences to your health care team.
Part 4's content related to organ and tissue donation aligns with the purpose of an Organ Donor Card. Both documents allow you to express your wishes about donating your organs and tissues after death, providing essential information to healthcare providers and family members.
By allowing you to outline funeral and burial wishes, Part 5 of the Advance Directive functions similarly to a Pre-Need Funeral Directive. This part ensures your end-of-life wishes, including the type of funeral or memorial service you desire, are known and can be acted upon by your designated representative or family members.
The inclusion of a Do Not Resuscitate (DNR) order in Part 7 parallels a standalone DNR form. These directives instruct health care providers not to perform CPR or other life-sustaining procedures if your heart stops or you stop breathing, crucial for those who wish not to receive such interventions.
Similar to an Emergency Medical Information form, the entire Advance Directive serves to communicate your health care preferences in detail, including conditions under which you would or wouldn't want specific treatments. This document functions as a comprehensive guide for your health care agent, family, and health care providers.
The directive's component where you can nominate a guardian if necessary resembles a Guardianship Nomination form. By nominating someone you trust to make decisions about your personal care and living arrangements if you're unable to do so, you're taking a proactive step similar to creating a formal guardianship arrangement.
Finally, the aspect of revocation and modification within the Maine Advance Directive shares characteristics with a Revocation of Health Care Directive form. It allows you the flexibility to change or cancel the directive, reflecting your right to adapt your advance care planning documents to match your current wishes.
When filling out the Maine Health Care Advance Directive Form, it's important to follow certain guidelines to ensure your health care wishes are clearly communicated. The following lists detail what you should and shouldn't do:
Do:
Review each section of the form carefully to understand the decisions you are being asked to make.
Choose a health care agent in Part 1 who you trust to make decisions on your behalf if you are unable to do so yourself.
Clearly communicate your treatment preferences in Part 2, if you have specific wishes about the care you want to receive.
Include the name of your primary physician, physician assistant, or nurse practitioner in Part 3.
Consider your options about organ donation, and fill out Part 4 if you wish to donate your organs, body, or tissues after death.
Specify your wishes for funeral and burial decisions in Part 5, whether by appointing someone to make these decisions after your death or outlining your preferences.
Ensure the form is signed and dated by you and two witnesses in Part 6.
Communicate your decisions to your physician, other health care providers, family, and hospital by providing them with copies of the completed form.
Talk with your lawyer, family members, physicians, and others close to you about your wishes before filling out the form.
Don't:
Leave parts of the form blank that you intend to use. Make sure to fill out each part that applies to your wishes.
Choose a health care agent who may not be willing, reasonably available, or able to make decisions for you.
Forget to specify at what point you want your health care agent to begin making decisions for you – immediately, or only when you are too sick to make them yourself.
Overlook nominating a guardian in case a court needs to appoint one for you, which can be done in the section provided for nominating a guardian.
Use vague language when detailing your specific health care wishes, treatments you want or do not want, and decisions about organ donation or funeral arrangements.
Forget to update the list of people who have copies of your signed health care advance directive if changes are made or if you complete a new form.
Modify Part 6 (signature and date) and Part 7 (Do Not Resuscitate order) as these sections cannot be changed.
Fail to initial each box and blank you fill in, to indicate that it was your decision.
Ignore the need to periodically review and update your form to ensure it still reflects your current wishes.
When it comes to the Maine Health Care Advance Directive Form, there are several common misconceptions that can lead to confusion. Understanding what the Advance Directive Form encompasses is essential for making informed decisions regarding one’s future medical care. Here are five such misconceptions:
Understanding these points helps clarify the purpose and flexibility of the Maine Health Care Advance Directive Form, ensuring that individuals can make informed decisions regarding their future health care in a way that best reflects their wishes and values.
The Maine Advance Directive form is a crucial document for anyone wanting to ensure their healthcare wishes are followed if they become too ill to communicate. Understanding how to fill out and use this form effectively is essential. Here are eight key takeaways to help guide you through the process:
Before completing the form, it’s recommended to discuss your wishes with family members, your physician, and possibly a lawyer. This ensures that your decisions are made with comprehensive advice and that those close to you understand your preferences. When any changes are made or a new form is completed, communicating these changes to everyone involved is crucial to ensure your wishes are honored.
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