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Maine ________________________________________________________________ (address of second witness) 5 witness) ______________________________________________________________________ (date) ______________________________________________________________________ (printed name of second witness) ______itness) ______________________________________________________________________ (address of first witness) ______________________________________________________________________ (signature of second nature of first witness) ______________________________________________________________________ (date) ______________________________________________________________________ (printed name of first wptional) (date) ______________________________________________________________________ (signature) SIGNATURES OF WITNESSES ______________________________________________________________________ (sig___________ (name) ______________________________________________________________________ (address) ______________________________________________________________________ (social security number - o_________ (phone) (13) EFFECT OF COPY: A copy of this form has the same effect as the original. (14) SIGNATURE Sign and date the form here: _____________________________________________________________________________________ (address) 4 ______________________________________________________________________ (city) (state) (zip code) _____________________________________________________________, I designate the following physician as my primary physician:: ______________________________________________________________________ (name of physician) ___________________________________________________________________________________________________________ (phone) (Optional) If the physician I have designated above is not willing, able or reasonably available to act as my primary physician physician) ______________________________________________________________________ (address) ______________________________________________________________________ (city) (state) (zip code) _______n PART 4 DESIGNATION OF PRIMARY PHYSICIAN (Optional) (12) I designate the following physician as my primary physician: ______________________________________________________________________ (name ofive any needed organs, tissues or parts, or ___ I give only the following organs, tissues or part: (11) MY GIFT IS FOR THE FOLLOWING PURPOSES: (i) Transplant (ii) Therapy (iii) Research (iv) Educatioe provided at all times, even if it hastens my death. (9) OTHER HEALTH CARE INSTRUCTIONS OR WISHES: (add additional pages if needed) 3 PART 3 DONATION OF ORGANS AT DEATH (10) UPON MY DEATH: ___ I gand hydration provided to me in order to prolong my life. (8) RELIEF FROM PAIN OR DISCOMFORT: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort becify that under the conditions mentioned in the above paragraph: ____ I do not want artificial nutrition and hydration provided to me in order to prolong my life. ____ I do want artificial nutrition its, OR ! Choice To Prolong Life: I want my life to be prolonged as long as possible within the limits of generally accepted health care standards. (7) ARTIFICIAL NUTRITION AND HYDRATION: I also spt time, (ii) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness or (iii) the likely risks and burdens of treatment would outweigh the expected benefce I have marked below: ! Choice Not To Prolong Life: I do not want my life to be prolonged if (i) I have an incurable or irreversible condition that will result in my death within a relatively shor 2 INSTRUCTIONS FOR HEALTH CARE (6) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the 2 choiI nominate the agent designated in this form. If that agent is not willing or reasonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated. PARTf I mark this box , my agent's authority to make health care decisions for me takes effect immediately. (5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, GENT'S AUTHORITY BECOMES EFFECTIVE: My agent's authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box. Ins for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent. (4) WHEN Aey for health care, any instructions I give in Section II of this form, and my other wishes to the extent known to my agent. To the extent my wishes are unknown my agent shall make health care decisio hydration and all other forms of health care to keep me alive, except as I state here: (3) AGENT'S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorn______ (home phone) (work phone) ( 2) AGENT'S AUTHORITY: My agent is authorized to make all health-care decisions for me, including decisions to provide, withhold or withdraw artificial nutrition and__________________________ (address) ______________________________________________________________________ (city) (state) (zip code) ________________________________________________________________cision for me, I designate as my second alternate: ______________________________________________________________________ (name of second alternate agent) ______________________________________________________________________ (home phone) (work phone) 1 If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably available to make a health care de______________________________________________ (address) ______________________________________________________________________ (city) (state) (zip code) ____________________________________________o make health care decisions for me, I designate as my alternate agent: ______________________________________________________________________ (name of first alternate agent) _____________________________________________________________________________________ (home phone) (work phone) (Optional) If I revoke the authority of my agent or if my agent is not willing, able, or reasonably available tof agent) ______________________________________________________________________ (address) ______________________________________________________________________ (city) (state) (zip code) _________FOR HEALTH CARE (1) DESIGNATION OF AGENT: I appoint the following person as my agent to make health care decisions for me: ______________________________________________________________________ (name and the designation of your primary physician. You may complete or modify all or any part of the following form or use a different form. ____________________________________ PART 1 POWER OF ATTORNEY also have the right to name someone else to make health-care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs rms is subject to the Disclaimers and Terms of Use found at findlegalforms.com Maine Advance Health Care Directive EXPLANATION You have the right to give instructions about your own health care. You ld have an attorney review it to make sure it fits your particular situation. You should also consult an attorney whenever a document is negotiated with another party. The purchase and use of these fome to time and from state to state. These forms should only be a starting point for you and should not be used without consulting with an attorney first. Before using or signing this document you shouMaine Advance Health Care Directive Information This package contains the Maine Advance Health Care Directive. These forms are not intended and are not a substitute for legal advice. Laws vary from ti Maine