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

Part 2

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.

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.
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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. ________________________________________________________________________

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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.

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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 agents name________________________________________________________________________
Title or relationship to me_________________________________________________________________
My agents address______________________________________________________________________
My agents home phone (___)___________________ My agents 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.
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Your agents 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 agents right to make decisions for me, change my agent or make
my own decisions. If I want to end my agents 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 (___)______________________________

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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.
OR
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

I do not want treatment to keep me alive if my
physician decides that either of the following is true;
(i) I have an illness that will not get better, cannot
be cured, and will result in my death quite soon
(sometimes referred to as a terminal condition),

Choice to be kept alive

I want to be kept alive as long as possible
within the limits of generally accepted health
care standards, even if my condition is
terminal or I am in a persistent vegetative
state.

OR
(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).

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Life-Sustaining Treatment Choices:

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 Alzheimers 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 Alzheimers disease or other severe dementia.

Choice not to be kept alive

If my physician and a second physician decide that I am
in the late stage of Alzheimers disease* or other severe
dementia, I do not want treatment to keep me alive.

Choice to be kept 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 Alzheimers disease or other severe
dementia.

* Only a physician can determine that someone is in the late stage of Alzheimers disease. People in the late
stages of Alzheimers 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.

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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:

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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:___________________

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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.
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Part 5 Instructions About

Funeral and Burial Arrangements
This section is optional. Fill out this part only if you wish to give special instructions about your funeral
or burial arrangements here.
I hope that my family will follow my wishes after I die as noted below.
I choose _____________________________________________________________ to have custody
and control of my body after my death with the right to decide everything about my funeral and burial.
OR
I want my family to know these are my wishes about: burial, cremation, funeral, or memorial service.
(Fill in)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

If you plan to die at home, talk with your physician and funeral director about your plans. When you die, your
family or agent should call your physician and the funeral home you have chosen. The funeral home staff will
pick up your body from your home.

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Part 6Signing the Form

If you have filled out any part of this form, you must sign and date the form on this page. You must also have two
other adults sign as witnesses at the same time you sign the form. Your agent cannot sign as a witness. You do not
need to have a Notary Public sign your Advance Directive form to make it legal in Maine. However, if you travel or
live part of the year out-of-state, it would be wise to have it signed by a Notary. Some states require this. You can
find this service under Notary Public in the phone book. Most banks also have Notaries Public and will usually
notarize papers for bank customers when asked. The Notary Acknowledgment may be done at any time after you
sign this form.
Sign and date the form here:
Sign your name: _________________________

Your Address:_________________________________

Print your name: _________________________

_____________________________________________

Date: __________________________________

_____________________________________________

First witness:
Signature: ______________________________
Print your name: ________________________

Address: _____________________________________
________________________________________________

Date: __________________________________ ________________________________________________

Second witness:
Signature: ______________________________
Print your name: ________________________

Address: _____________________________________
________________________________________________

Date: __________________________________ ________________________________________________

Notary Acknowledgment.
Then personally appeared the above named __________________________________, known to me or who
presented satisfactory evidence of his/her identity, and acknowledged this Advance Directive as his/her free act and
deed before me.
Notary signature: _______________________________________________

Date: ___________________

Printed name: ______________________ Notary Public State of:___________ Commission Exp.: _________
Make sure to tell people. Tell your family members, physicians and others close to you what you have decided.
You should talk to the agent(s) you have chosen to make sure that they understand your wishes and are willing to
carry them out. Give a copy of this form to your physician, to any place where you get health care, and to any
agent(s) you have chosen in Part 1. Please be sure to list the people who have copies of this form on the front page.
Canceling or changing the form.
Part 1: You may end your agents right to make decisions while you are still able to make those decisions by telling
your primary physician or putting your decision in writing and attaching it to this form. If you want to name a new
agent, you must put that instruction in writing and sign it in front of two witnesses who must also sign their names.
Parts 2-7: You may cancel any other part of this form, or change your instructions in the other parts of this form
while you are still able to make those decisions. It is best to do so by (1) writing on this form, (2) writing on another
piece of paper and attaching it to this form, or (3) completing a new form. Any of those written changes should be
signed and dated by you.
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Part 7Instructions to Emergency Medical Services

(ambulance crews) about what to do if your heart or breathing stops.
This section is optional. If you do not want ambulance crews to revive you if your heart or breathing stops,
you and your physician (or nurse practitioner or physician assistant) must both complete and sign this part.
Instructions for Part 7:

If I stop breathing or my heart stops, I do not want the Emergency Medical Services (ambulance crews)
to try to revive me. My physician (or nurse practitioner or physician assistant) and I have discussed
this and signed the special form on the next page. I understand that this decision will not prevent me
from receiving other emergency care, or comfort care from health care workers before I die.

I understand that the form goes into effect when I have signed it AND it is signed by my physician (or
nurse practitioner or physician assistant).

I understand that this directive will not be followed unless my family, caretaker or I give the signed
form on the next page to Emergency Medical Services (ambulance crews), and that it is solely my
responsibility to make sure they see it.

I understand that I should carry the signed form with me unless I wear health alert jewelry, such as
MedicAlert, that also tells people that I do not want to be revived if my heart or breathing stops (Please
call Maine Emergency Medical Services at 207-626-3860 to see if there are other Maine EMS approved
health alert jewelry companies).

I understand that if any health care provider has any doubts about what I want, they will try to restart
my heart or breathing.

I understand that I may revoke this directive at any time by destroying this form and removing any
Maine EMS approved Do-Not-Resuscitate jewelry. I can also tell the ambulance crews that I have
changed my mind.

I understand that should I change my mind, it is my responsibility to tell my physician (or nurse
practitioner or physician assistant) and other people who have copies of the signed form.

If I want my agent to make this decision later, my agent should take the form available at:
http://www.maine.gov/dps/ems to my physician (or nurse practitioner or physician assistant) when it is
time to make the decision.

If you complete and sign this section, put the original in a safe place and be sure to give copies to
ambulance crews, your family, your caregivers, and your physician.

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DO-NOT-RESUSCITATE (DNR) DIRECTIVE

This section is optional. If you do not want ambulance crews to revive you if your heart or breathing
stops, you and your physician (or nurse practitioner or physician assistant) must complete and sign this
form.
FOR PATIENT TO COMPLETE after consultation with his or her health care provider:
In the event that my heart or breathing stops and I am unable to speak for myself, I, ___________________
(printed name)direct that no efforts be taken to restart my heart or breathing and that Emergency
Medical Services (ambulance crews) if notified, honor my directive. I have come to this decision after
considering my condition and prognosis and the potential risks, burdens and benefits of refusing efforts to
restart my heart or breathing.
I understand that I may change my mind at any time by destroying this form and removing any Maine
EMS approved Do-Not-Resuscitate jewelry, such as MedicAlert. I will also tell my physician (or nurse
practitioner or physician assistant) and other caregivers if I change my mind.
I understand that this form is not valid until my physician (or nurse practitioner or physician assistant)
and I have signed it.
I understand that in a hospital, nursing home, hospice or home health setting, federal law requires that
my physician must include a specific DNR order in my medical record or plan of care, even if we have
both signed this form.
No expiration date

OR

Expires on _______________________________________

____________________________________________________
Patient Signature

________________________
Date Signed

FOR PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER TO COMPLETE:

By my signature I affirm that:
(i) After meeting with this patient and discussing this decision, I am satisfied that the patient understands
the potential risks, burdens and benefits of refusing resuscitative interventions in light of the patients
medical condition; and (ii) I believe that the patient has made a voluntary informed decision about
resuscitation and I agree to comply with that decision. I will tell any health care providers providing
care under my authority to comply with this decision.
________________________________________
Signature and license level (MD, DO, PA or NP)

________________________________________
Date Signed

________________________________________
Printed Name

________________________________________
Telephone Number

THIS FORM IS ENDORSED BY MAINE EMERGENCY MEDICAL SERVICES

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