Fillable Printable Power of Attorney for Health Care Will to Live Form - Maine

Power of Attorney for Health Care Will to Live Form - Maine

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Maine Power of Attorney for Health Care

Will to Live Form

I, (your name)__________________________________________________________________

(your address)__________________________________________________________________

_____________________________________________________________________________

(your phone number)____________________________________________________________

designate:

(Name of agent)________________________________________________________________

(address of agent)_______________________________________________________________

(phone number(s) of agent)________________________________________________________

as my health care agent to make any health care decisions for me as authorized in this document

consistent with the instructions below.

If the person I appoint above refuses or is not able to act for me, I appoint the following persons

(each to act alone and successively, in the order named):

A. First Successor Agent

(successor agent’s name)_________________________________________________________

(successor agent’s address)________________________________________________________

_____________________________________________________________________________

(successor agent’s phone number)__________________________________________________

B. Second Successor Agent

(second successor agent’s name)___________________________________________________

(second successor agent’s address)__________________________________________________

______________________________________________________________________________

(second successor agent’s phone number)____________________________________________

as my health care agent to make any health care decisions for me as authorized in this document

consistent with the instructions below.

This designation shall become effective when it is communicated to my attending physician and

it is determined by my attending physician that I am no longer able to make or communicate

decisions regarding administration of life-sustaining treatment and that I have an incurable and

irreversible condition that without the administration of life-sustaining treatment will, in the

opinion of my attending physician, result in my death within a relatively short time.

Any prior designation is revoked.

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GENERAL PRESUMPTION FOR LIFE

I direct my health care provider(s) and health care attorney in fact(s) to make health care

decisions consistent with my general desire for the use of medical treatment that would preserve

my life, as well as for the use of medical treatment that can cure, improve, reduce or prevent

deterioration in, any physical or mental condition.

Food and water are not medical treatment, but basic necessities. I direct my health care

provider(s) and health care attorney in fact to provide me with food and fluids, orally,

intravenously, by tube, or by other means to the full extent necessary both to preserve my life

and to assure me the optimal health possible.

I direct that medication to alleviate my pain be provided, as long as the medication is not used in

order to cause my death.

I direct that the following be provided:

C the administration of medication;

C cardiopulmonary resuscitation (CPR); and

C the performance of all other medical procedures, techniques, and technologies,

including surgery,

–all to the full extent necessary to correct, reverse, or alleviate life-threatening or health

impairing conditions or complications arising from those conditions.

I also direct that I be provided basic nursing care and procedures to provide comfort care.

I reject, however, any treatments that use an unborn or newborn child, or any tissue or organ of

an unborn or newborn child, who has been subject to an induced abortion. This rejection does

not apply to the use of tissues or organs obtained in the course of the removal of an ectopic

pregnancy.

I also reject any treatments that use an organ or tissue of another person obtained in a manner

that causes, contributes to, or hastens that person’s death.

I request and direct that medical treatment and care be provided to me to preserve my life

without discrimination based on my age or physical or mental disability or the “quality” of my

life. I reject any action or omission that is intended to cause or hasten my death.

I direct my health care provider(s) and health care attorney in fact to follow the policy above,

even if I am judged to be incompetent.

During the time I am incompetent, my attorney in fact, as named below, is authorized to make

medical decisions on my behalf, consistent with the above policy, after consultation with my

health care provider(s), utilizing the most current diagnoses and/or prognosis of my medical

condition, in the following situations with the written special instructions.

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WHEN MY DEATH IS IMMINENT

A. If I have an incurable terminal illness or injury, and I will die imminently – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only a week or less even

if lifesaving treatment or care is provided to me – the following my be withheld or withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

WHEN I AM TERMINALLY ILL

B. Final Stage of Terminal Condition. If I have an incurable terminal illness or injury and even

though death is not imminent I am in the final stage of that terminal condition – meaning that a

reasonably prudent physician, knowledgeable about the case and the treatment possibilities with

respect to the medical conditions involved, would judge that I will live only three months or less,

even if lifesaving treatment or care is provided to me – the following may be withheld or

withdrawn:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

C. OTHER SPECIAL CONDITIONS:

(Be as specific as possible; SEE SUGGESTIONS.):

______________________________________________________________________________

(Cross off any remaining blank lines.)

IF I AM PREGNANT

D. Special Instructions for Pregnancy. If I am pregnant, I direct my health care provider(s) and

health care attorney in fact(s) to use all lifesaving procedures for myself with none of the above

special conditions applying if there is a chance that prolonging my life might allow my child to

be born alive. I also direct that lifesaving procedures be used even I am legally determined to be

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brain dead if there is a chance that doing so might allow my child to be born alive. Except as I

specify by writing my signature in the box below, no one is authorized to consent to any

procedure for me that would result in the death of my unborn child.

If I am pregnant, and I am not in the final stage of a terminal condition as defined above,

medical procedures required to prevent my death are authorized even if they may result in the

death of my unborn child provided every possible effort is made to preserve both my life and the

life of my unborn child.

____________________________________

Signature of Declarant

Signed this ____________________day of ___________________________, 20_______.

Signature______________________________________________________________________

Address

Date of Birth or Social Security Number

The principal voluntarily signed this writing in my presence.

First Witness Signature:__________________________________________________________

Residence Address:______________________________________________________________

Second Witness Signature:________________________________________________________

Residence Address:______________________________________________________________

form prepared 2001

*clerical changes made 11/05