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Maine Advance Health Care Directive | POA & Living Will

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A Maine Advance Health Care Directive, also known as a power of attorney or living will, gives its users the opportunity to choose another person to make their health care decision in the event they are unable to do so on their own. In addition, the option to cover end of life preferences, burial arrangement, and other common concerns have been included on this form. You may also include a do not resuscitate order.

Definition – § 5-801(a)

Laws – 18-A §5-802 (Advance health-care directives)

Durable Power of Attorney – Allows a person to choose an agent to make their financial decisions.

How to Write

1 – You Should Access The Health Agent Delegation Paperwork On This Page

This directive may be opened using the buttons on the page near the image. Each one has been labeled according to the file type it connects to. Click on the button to open this form. It may be worked on with a form friendly browser, compatible software, or printed then filled out.

2 – Fill Out Part One To Name A Health Care Agent

The Principal granting approval for an Agent to make Health Care Decisions on his or her behalf will be able to declare such a person in Part One. First, in the area below the word “Note,” the Principal must self-report on some information.

The Principal Must Print his or her Name on the blank line following the words “My Name.”  On the empty line directly below the Name, the Principal must present his or her Home Address using the space after the words “My Address”Finally, the Principal must supply his or her Date of Birth on the empty line after the words “My Birth Date.”

The statement beginning with “This is a list…” will contain ten blank lines. These lines have been provided so that each individual or entity the Principal will give a copy of this directive to may be listed. Part One will begin with the heading “Your Advance directive Begins Here.” Here, beneath the “Choosing an Agent” statement, the Principal’s Agent may be documented adequately for the purposes of this paperwork.

On the blank line labeled “My Name,” the Full and Legal Name of the individual delegating the Power to make Health Care Decisions on his or her behalf to another individual should be recorded. The next blank line, “My Agent’s Name,” enter the Legal Name of the individual who will be granted to the Power to make Health Care Decisions on behalf of the Principal once this form is executed correctly. This entity’s name should be reported precisely as it appears on his or her personal Identification.

The role of the Health Care Agent in the Principal’s life should be included in this report. On the blank line labeled “Title or Relationship To Me,” describe how the Health Care Agent named above is related to the Principal. For instance, the Health Care Agent may be the Principal’s Brother-in-Law or Attorney. The location where the Health Care Agent may be physically found must be reported on the blank space labeled “My Agent’s Address.” This should be the Health Care Agent’s Residential Address. On the next blank line, there will be two blank spaces. Use the first one to report the Health Care Agent’s Home Telephone Number and use the second one to report the Health Care. Agent’s Telephone Number at work. Any phone number here must be (and remain) up-to-dateDue to the Nature of this paperwork, there are two additional sections here so that two additional Health Care Agents may be named as Successor Agents. If the Primary Health Care Agent is unable or unavailable to act as the Principal’s Health Care Agent, the individual named under the heading “Choice #2 To Be My Agent” will be empowered through this paperwork to take over the role of the Principal’s Health Care Agent. Use the blank spaces to enter the Name, Title or Relationship with the Principal, Address, Home Telephone Number, and Work Telephone Number of the Successor Agent. The area beneath the words “Choice #3 To Be My Agent” is reserved so that you may report a second Successor Agent. That is, an individual to assume the Primary Health Care Agent role should both the original choice and the Successor Agent be unable to assume the position. Use the blank lines provided to enter the Second Successor Agent’s Name, Title, Address, Home Phone Number, and Work Telephone Number. While other Entities are obliged to recognize the Principal Power of the Health Care Agent’s listed here, the Principal may change his or her mind about who may be the Primary Health Care Agent. Below the area where the Successor Agents were named, will be a precautionary statement. If at any point the Principal wishes to rescind the Power given to an Agent here, he or she need only fill in the Name of the Agent (whose Power is being revoked) on the first blank space after the words “I do not want,” sign his or her Name on the “My Signature” line, and the Date the Signature was supplied. Next, beneath the statement “When Your Agent Can Start Making Decisions,” a definition to the durability of these Powers will be defined. If the Principal wishes the Agent to make decisions only if a judge or physician has declared the Principal unable to, mark Choice A. If the Principal wishes to retain the right to be informed, change his or her mind, override the Health Care Agent’s decisions or revoke the Health Care Agent’s Power on site verbally, then mark Choice B.The “Nominating A Guardian” section will give an area so the Principal may choose to Nominate the Health Care Agent Named here as his or her Guardian of Estate should the courts decide one is needed. If so, then mark the box labeled “I nominate my agent to be my guardian…”If the Principal wishes to Nominate a separate individual to act as his or her Guardian for the Court’s consideration at a time the Courts decide one should be appointed, then leave the above checkbox unmarked. The Principal may then enter the Name, Title, Address, Home Telephone Number, and Work Telephone Number on the blank lines provided. 3 – Principal Preferences And Instructions Will Be Documented In Part Two

 

 

Part 2 may be used to outline the Principal’s preferences in certain end-of-life scenarios whether an Agent has been named in Part One, though it is customary for the Agent to be fully informed of all the declarations made here. It should be noted, however, that an Agent will not be able to override anything said here.

To begin, locate the first table below the heading “Life-Sustaining Treatment Choices.” Two boxes have been provided here, only one of which may be chosen. If the Principal does not wish to be kept alive in the event he or she has a terminal illness or falls into a coma, the box labeled “Choice Not To Be Kept Alive” should be marked. If the Principal wishes to be kept alive if it is within the generally accepted standards noted in health care, then mark the box labeled “Choice To Be Kept Alive.”The next table will also contain two boxes of which one must be chosen. If the Principal does not wish to be kept alive once being diagnosed with the late stages of Alzheimer’s Disease or some other (severe) Dementia, the Principal will need to mark the box just above the words “If my physician and a second physician…” If the Principal wishes to be kept alive if possible even if in the late stages of Alzheimer’s Disease or another case of severe dementia, the Principal should mark the box above the words “I want treatment to keep me alive…”

Now, locate the bold words “Tube Feeding.” If the principal does not wish to be given life-sustaining nutrition and hydration, the checkbox next to the words “Artificial nutrition and hydration…” must be marked. If the Principal does wish to be given Artificial Nutrition and Hydration when necessary, the box next to the words “Artificial nutrition and hydration…”Locate the table below the bold words “Relief from Pain.” If the Principal wishes to be given relief from pain or discomfort even if such treatment causes drowsiness or death, then mark the box next to the words “I want treatment…” If the Principal has specific preferences regarding pain relief, then use the blank lines below the words “These are my wishes…” to record these instructions. If there are more directions the Principal wishes to issue, they may be documented on the blank lines under the words “Other Directions.” If more room is required, simply cite an attachment with these instructions.4 – The Principal’s Primary Physician May Be Named In Part Three

The next area will allow the Principal to record the Name(s) of his or her Primary Physician. The Principal may also name a secondary Primary Physician, Physician Assistant, and/or Nurse Practitioner to speak to before engaging in any treatment.

Use the blank line labeled “Name of My Primary Physician” under the heading “Part 3 – Primary Physician,” to report the full name of the Principal’s Primary Physician. Make sure to report this entity’s Address and Telephone Number on the blank lines labeled “Address” and “Phone.”If the Agent cannot contact the Primary Physician listed or the Primary Physician is not available, a second choice may be named for the Agent to contact. On the second set of lines, use the spaces labeled “Name of Physician,” “Address,” and “Phone” to document a second choice the Agent may contact. If the Principal also wishes the Agent to speak to a specific Nurse Practitioner or Physician Assistant, then use the blank line labeled “Name of Nurse Practitioner or Physician Assistant,” “Address,” and “Date” to report the Identity and Contact Information of this party.

5 – Organ Donation And Other Anatomical Gifts Will Be Addressed In Part Four

The next part, “Donation of Body, Organs or Tissues At Death,” supplies a specific area for the Principal to disclose his or her Preferences regarding Anatomical Gifts at the time of the Principal’s Death.” This section is optional and provided for the convenience of the Principal.

If the Principal does not wish to make an Anatomical Gift of his or her body, body parts, organs, or tissues then mark the box next to the words “I do NOT wish to donate any organs, tissues or parts” at the top of the page.

If the Principal does wish to make an Anatomical Gift, he or she may document any preferences in the next area. If the Principal wishes to donate his or her entire Body, then mark the box labeled “I give my body.” If the Principal wishes to donate organs, tissues or parts, then mark the box corresponding to the statement “I give any needed organs, tissues or Parts.If the Principal only wishes to donate specific organs, tissues or body parts, then mark the box labeled “I give only the following organs…”The Principal may also declare why the Anatomical Gift should be made. If the Anatomical Gift should be made for the purposes of therapy or as a transplant, then mark the box next to the statement “My Gift Is For Transplant Or Therapy.” If the Principal is making an Anatomical Gift for Research or Education, then mark the second box. In this option, there will be a Name and Address line to document any interested entity the Principal wishes the Anatomical Gift to be donated to.

6 – Funeral Arrangements And Other Post Death Decisions May Be Handled In Part Five

The next page, “Part 5 – Instructions About Funeral And Burial Arrangements,” will provide two choices to illustrate the Principal’s preferences as to what should happen to his or her remains.

If the Principal wishes to name a specific individual to take custody of his or her remains, then mark the first box in this section then, enter the Full Name of the individual to take custody of the Principal’s remains on the blank line provided. If the Principal instead prefers to simply document his or her preferences, this may be done by marking the second checkbox and using the blank lines provided to report them. If there is not enough room, you may add more with the appropriated editing software or simply cite an attachment.

7 – Principal And Witness Signatures Are Required Items Of Verification For This Form

Part Six will provide an area for the Principal and two Witnesses to satisfy this form’s requirements for execution.

Locate the bold sentence “Sign And Date The Form Here” The Principal must sign and print his or her Name, provide his or her Address, then enter the “Date” he or she is signing this document.

Below this area, there will be a set of lines for the “First Witness” and a set of lines for the “Second Witness” to sign his or her Name, print his or her Name, enter his or her Address, and record the Date he or she signed this form. Note: Each Witness should sign this form on the same Date as the Signature. The “Notary Acknowledgment” section has been provided in case the Principal has this signing Notarized. While not mandatory, it is strongly recommended.

8 – The Optional Do Not Resuscitate Form

The last page of this paperwork is titled “Do-Not-Resuscitate (DNR) Directive.” If the Principal does not wish to be resuscitated in a medical emergency, he or she must sign it. Before signing it,

First, enter the Principal’s Name on the blank line in the first blank line.  The Principal must decide if an Expiration Date will apply. If the DNR should remain in effect indefinitely, then mark the box labeled “No Expiration Date.” If the Principal does wish an Expiration Date to terminate the effectiveness of this DNR, then mark the box labeled “Expires On” then enter the Date this order terminates on the blank line provided. Below this, the Principal must sign the blank line labeled “Patient Signature” and enter the Date when this Signature was committed on the blank line labeled “Date Signed”

The rest of this form should be filled out by the attending Physician, Physician Assistant, or Nurse Practitioner.


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