Maine Living Will Form (Advance Directive)

The Maine Advanced Directive, is a form which is drawn up in accordance to Statutes tit. 18- A, § 5-801 to -817 giving a person, referred to as a `Principal`, the right to express their medical health and end of life wishes  should they become unable to do so through illnesses like serious Dementia or a coma. The form is completed in writing and requires two witnesses. It is invalid if they are found to be pregnant.

How to Write

Principal

The principal must enter their personal details.

  • Name.
  • Address.
  • Date of birth.
  • Details of persons with copies of this completed living will document.

 

PArt 1: Advanced Health Care Directive

 

Choosing An Agent

The principal must select an agent and alternative agents.

  • Principal`s name.
  • Agent`s names.
  • Relationship to agents.
  • Agent`s addresses.
  • Agent`s home/work telephone numbers.

 

Deselecting An Agent

The principal can choose not to give any agent the power of attorney.

  • Name of agent.
  • Principal`s signature.
  • Date.

 

Agent`s Power

The principal must select when the agents authority becomes effective.

  • Check box to signify the agent`s authority becomes effective when a primary physician or judge decides.
  • Check box to signify the agent`s authority becomes effective immediately.

 

Guardians

The principal may select a guardian.

  • Check box to nominate the agent as the principals guardian.

Or enter specific details of a guardian nominated by the principal.

  • Name.
  • Title/relationship.
  • Address.
  • Home/Work telephone number.

 

PArt 2: Special Instructions

 

Life Sustaining Treatments

The principal must select the whether or not they require life sustaining treatment.

  • Check box to NOT receive life sustaining treatment in the event of an incurable illness or if consciousness will not be regained.
  • Check box to receive life sustaining treatment as long as possible regardless.
  • Check box NOT to receive lie sustaining treatment if suffering from late stage Alzheimer`s disease or Dementia.
  • Check box to receive life sustaining treatment even if if suffering from late stage Alzheimer`s disease or Dementia.
  • Check box to NOT receive artificial hydration and nutrition.
  • Check box receive artificial hydration and nutrition.
  • Check box to receive relief from pain where ever possible.
  • Enter specific details of any other personal requirements the principal has regarding the treatment to sustain life.

 

Part 3: Primary Physician

The principal must name a primary physician and an alternative primary physician or nurse practitioner.

  • Names of physicians.
  • Addresses of physicians.
  • Telephone numbers of physicians.
  • Name of nurse.
  • Address of nurse.
  • Telephone number of nurse.

 

Part 4: Donation

The principal can decide regarding the donation of the body, organs and tissues.

  • Check the box to NOT donate organs, tissues or parts.
  • Check the box to give the principal`s body.
  • Check the box t give any needed organs, tissues or parts.
  • Check the box and enter the specific details of any organs, tissues or parts to be donated.
  • Check the box to donate for the purposes of transplant or therapy.
  • Check the box to donate for the purposes of research and education.
  • Enter the details of a preferred institute to receive the donation (Optional).

 

Part 5: Funeral & Burial

The principal decides the specific details for their funeral and burial.

  • Check the box and enter the name of a person to be given custody of the principal after death.
  • Check the box and enter specific details of requirements for the principal after their death.

 

Part 6: Signatures

The details of those involved with this document must be entered,

  • Principal`s signature.
  • Principal`s name.
  • Principal`s address.
  • Date.
  • Witnesses signatures.
  • Witnesses names.
  • Witnesses addresses.
  • Date.
  • Principal`s name.
  • Notary`s signature.
  • Date.
  • Notary`s name.
  • Notary`s state.
  • Date of expiration of notary`s commission.

 

Do Not Resuscitate (DNR) Directive (Optional)

The principal and the physician must enter their personal details to authorize the DNR Directive.

  • Principal`s name.
  • Check box to signify no expiration date of document.
  • Check box and enter specific date of expiration of document.
  • Principal`s signature.
  • Date.
  • Signature an licensed level of physician.
  • Name of physician.
  • Telephone number.
  • Date.