Living Will Forms > Free Maine Living Will Forms | Advance Health Care Directive > Maine Living Will Form (Advance Directive)

Maine Living Will Form (Advance Directive)

The Maine Advanced Directive is a form that is drawn up in accordance with Statutes tit. 18- A, § 5-801 to -817 gives 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.

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.