Maine Power of Attorney for Health Care Will to Live Form

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
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