Advancedirective Form

MaineHealthCare

AdvanceDirective Form

Youmayusethisformnowtotellyourphysicianandotherswhatmedicalcareyouwanttoreceiveifyoubecometoosickinthefuturetotellthemwhatyouwant. YoumaychoosetofilloutthewholeformoranypartoftheformandthensignanddatetheforminPart6.Thesearetheparts:

Note

YoumaychangeanypartofthisformexceptforPart6andPart7. Youmaycrossoutanywords,sentences,orparagraphsyoudonotwant. Youcanalsoaddyourownwords. Ifyoumakeanychangestotheform,itisbestifyouputyourinitialsandthedatenexttoeachchangesothateveryoneknowsitwasyourdecisiontomake

thechange. Theformletsyouchoosedifferentwaystohandleyourcarebycheckingboxesorfillinginblanks.Youmayinitialeachboxandeachblankyoufillintoshowthatitwasyourdecisiontochecktheboxorfillintheblank.

Beforefillingoutthisform,wesuggestthatyoutalkwithyourlawyer,familymembers,physicians,andothersclosetoyouaboutyourwishes.Ifyoumakechangesorcompleteanewform,besuretoleteveryoneknow.

MyName(pleaseprint)

MyAddress

MyBirthdate

Thisisalistofallthepeoplewhohavecopiesofmysignedhealthcareadvancedirective:

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Part1–PowerofAttorneyforHealthCare

Instructions:

Thispartletsyouchooseanotherpersontomakehealthcaredecisionsforyou,eitherrightawayorwhenyouaretoosicktochooseyourowncare. Thepersonyouchooseiscalledyouragent. Youmayalsonamea

secondandthirdchoicetobeyouragent,ifyourfirstchoiceisnotwilling,reasonablyavailableorabletomakedecisionsforyou. Ifyouchooseanagentonthisform,butdonotfilloutanyotherpartsoftheform,your

agentwillbeableto:

• Makeallhealthcaredecisionsforyou,includingdecisionsregardingtests,surgeryandmedication;

• Decidewhetherornottohavefoodorfluidsgiventoyouthroughtubesorfedintoyourveinsthroughan

IV;

• Decidewhetherornottousetreatmentsormachinestokeepyoualiveortorestartyourheartorbreathing;

• Choosewhowillgiveyouhealthcareandwhereyouwillgetit,suchashospitals,nursinghomes,assistedlivingsettings,homehealth,orhospicecare;and

• Makeanyhealthdecisionheorshebelieveswouldbeconsistentwithyourvaluesorinyourbestinterest,evenifitisnotlistedintheform.

Whocanbeyouragent:

Youcannameanyadultyoutrusttobeyouragent,exceptyouragentmaynotbetheowner,operatororemployeeofanursinghomeorresidentiallong-termcarefacilitywhereyouarereceivingcare,unlessthatpersonisyourrelative.

Howyouragentmustmakedecisions:

Ifyouragentdoesnotknowwhatyouwant,theagentmustmakedecisionsconsistentwithyourpersonalvalues,ifknown,orbasedonyourbestinterests. InPart2,youcandecidewhatyouwantinadvance. IfyoumakechoicesinPart2,youragentmustmakedecisionsbasedonthosechoices.

Whocanseeyourhealthcareinformation:

Onceyouragenthastherighttomakehealthcaredecisionsforyou,youragentcanlookatyourmedicalrecordsandconsenttogivingyourmedicalinformationtoothers. Thestateandfederalprivacylawsletyouragentseeallofyourhealthinformationsothatheorshecanmaketherightdecisionforyou.

Thefirstpartofyouradvancedirectivebeginsonthenextpage.

YOURADVANCEDIRECTIVEBEGINSHERE

Choosinganagent: Fillinyournameandthenameofthepersonyouchoosetobeyouragenttomakehealthcaredecisionsforyouhere:

Myname

Myagent’sname

Titleorrelationshiptome

Myagent’saddress

Myagent’shomephone()Myagent’sworkphone()

IftheagentIhavenamedaboveisnotwilling,reasonablyavailableorabletomakedecisionsforme,Ichoosethefollowingpersontobemyagent:

Choice#2tobemyagent

Name

IfthepersonIhavenamedasChoice#2isnotwilling,reasonablyavailableorabletomakedecisionsforme,Ichoosethefollowingpersontobemyagent:

Choice#3tobemyagent

Name

TitleorRelationshiptome

TitleorRelationshiptome

Address

Address

HomePhone()

HomePhone()

WorkPhone()

WorkPhone()

Youmaychangeyourmindlateraboutwhoyouwanttobeyouragent. Ifyouwanttostoptheagentyouhavenamedfrommakingdecisionsforyou,youmusttellyourprimaryphysicianorfillintheseblanks:

Idonotwant

tobemyagent.

Mysignature

Dateyoufilledoutandsignedthissection

Anytimeyoucancel,replaceorchangethisformyoushouldgivecopiesofthechangedornewformtoeveryonewhohasacopyofyouroriginalform.

Youragent’spower:

Whenyouragentcanstartmakingdecisionsforyou: (Checkonlyonebox: A orB)

A. MyagentcanmakedecisionsonlywhenmyprimaryphysicianorajudgedecidesthatIamtoosicktomakemyownhealthcaredecisions.

OR

B. Myagentcanstartmakinghealthcaredecisionsformerightaway,butthisdoesnotmeanIhavegiven

uptherighttomakemyowndecisionsifIamstillableandwillingtomakemyowndecisions. Whenmyagentmakesahealthcaredecisionforme,Iwillbetold,ifpossible,aboutthatdecisionbeforeitiscarriedoutunless

IsayIdonotwanttoknow. IfIdisagreewiththatdecisionandamstillabletodecide,Icanmakeadifferentdecision. AslongasIamable,Icanendmyagent’srighttomakedecisionsforme,changemyagentormakemyowndecisions. IfIwanttoendmyagent’srighttomakedecisionsforme,Imusttellmyprimaryphysicianorputmydecisioninwritingandsignitwiththedateofmysignature.

Nominatingaguardian:

Aguardianisapersonchosenbyacourttomakedecisionsaboutyourpersonalcare. Thesedecisionscanincludenotonlyhealthcare,butotherdecisionssuchaswhereyouwillliveandhowyourpersonalneedswillbemet. Ifyouwish,youmayaskthatacourtassignyouragentasyourguardian,ifappointmentofaguardianshouldbecomenecessary. Checktheboxbelowtonominateyouragenttobeyourguardian,ifajudgeneedstoappointaguardianforyou.

Inominatemyagenttobemyguardianifajudgeneedstoappointaguardianforme.

Ifyouwanttonominatesomeoneotherthanyouragenttobeyourguardian,youmayfillinthesectionbelow.

Ifajudgeneedstoappointaguardianforme,Inominatethepersonnamedbelowasmyguardian:

NameTitleorRelationshiptome

Address

HomePhone ()

WorkPhone ()

Part2–SpecialInstructions

InstructionsifyoudidnotnameanagentinPart1:

IfyoudidnotnameanagentinPart1,youshouldfilloutthisParttostatewhatyouwantforcareifyoubecometoosicktomakeyourchoicesknown.

OR

InstructionsifyoudidnameanagentinPart1:

IfyounamedanagentinPart1,youdonothavetofilloutthispartoftheform. Ifyouwantyouragenttomakeallofyourhealthcaredecisions,DONOTfilloutthispartoftheform. Youragentwillmakedecisions

inyourbestinterests,includingdecisionstorefusetreatment. However,youmayfilloutthispartifyouwanttogivespecialdirectionstoyouragentaboutyourwishes,suchaswhenyouareneardeath,inapermanentcoma

ornolongerabletomakeyourowndecisions. Youmayalsocrossoutoraddwords. Itisbestifyouputyourinitialsanddatenexttoanychangesyoumakesoeveryoneknowsthechangeswereyourdecision. Ifyoucompletethispart,yourphysicianandotherswillfollowtheseinstructionsandyouragentcannotmakeadifferentdecision. Youmayalsowriteyourwishesonanotherpieceofpaper,signit,dateit,andkeepitwiththisform.

Life-SustainingTreatmentChoices:

Youmaycheckoneofthetwoboxesbelowtoshowyourchoiceaboutgettingtreatmentsthatwouldkeepyoualive:

Choicenottobekeptalive

Idonotwanttreatmenttokeepmealiveifmyphysiciandecidesthateitherofthefollowingistrue;

(i)Ihaveanillnessthatwillnotgetbetter,cannotbecured,andwillresultinmydeathquitesoon(sometimesreferredtoasaterminalcondition),

OR

(ii)Iamnolongeraware(unconscious)anditisverylikelythatIwillneverbeconsciousagain(sometimesreferredtoasapersistentvegetativestate).

Choicetobekeptalive

Iwanttobekeptaliveaslongaspossiblewithinthelimitsofgenerallyacceptedhealthcarestandards,evenifmyconditionisterminalorIaminapersistentvegetativestate.

Life-SustainingTreatmentChoices:

Youmayalsocheckoneofthetwoboxesbelowtoshowyourchoiceabouttreatmentthatwouldkeepyoualiveif,inthefuture,youhavelatestageAlzheimer’sdiseaseorotherseveredementia. Thesechoiceswillnotlimittheauthorityunderstatelawforyouragent,surrogate,guardianorphysiciantomaketreatmentchoicesifyouareunabletomakeyourowndecisionsandarenotinlatestageAlzheimer’sdiseaseorotherseveredementia.

Choicenottobekeptalive

IfmyphysicianandasecondphysiciandecidethatIaminthelatestageofAlzheimer’sdisease*orotherseveredementia,Idonotwanttreatmenttokeepmealive.

Choicetobekeptalive

Iwanttreatmenttokeepmealiveaslongaspossiblewithinthelimitsofgenerallyacceptedhealthcarestandards,evenifmyphysicianandasecondphysiciandecidethatIaminthelatestageofAlzheimer’sdiseaseorotherseveredementia.

*OnlyaphysiciancandeterminethatsomeoneisinthelatestageofAlzheimer’sdisease. PeopleinthelatestagesofAlzheimer’sdiseasegenerallyhaveanumberofthefollowingcharacteristics: lossoftheabilitytorespondtotheirenvironment;lossoftheabilitytospeak;lossoftheabilitytocontrolmovement;lossofthecapacityforrecognizablespeech,althoughwordsorphrasesmayoccasionallybeuttered;needinghelpwitheatingandtoileting;generalincontinenceofurine;lossoftheabilitytowalkwithoutassistance,thentheabilitytositwithoutsupport,thentheabilitytosmile,andtheabilitytoholdtheirheadup;reflexesbecomeabnormal;musclesgrowrigid;andswallowingisimpaired.

TubeFeeding:YoumaycheckoneofthetwoboxesbelowtoshowyourchoiceabouttubefeedingorhavingwaterandnutritionfedintoyourbodythroughanIVortube(artificialnutritionandhydration):

Artificialnutritionandhydrationshouldnot

begiven,orshouldbestopped,basedontheotherlife-sustainingtreatmentchoicesImadeaboutkeepingmealiveonPages6and7.

Artificialnutritionandhydrationshouldbe

givenregardlessofmycondition.

RelieffromPain:Youmaychecktheboxorfillintheblanksbelowtoshowyourchoiceaboutreliefofpainordiscomfort.

Iwanttreatmentforreliefofpainor

discomforttobegivenatalltimes,evenifitshortensthetimeuntilmydeathormakesmedrowsy,

Thesearemywishesaboutreliefofpainordiscomfort:

unconsciousorunabletodoother

things.

OtherDirections:

Youmaygivemoredirectionsoraddanyothertreatmentchoicesinthespacebelow:

Part3—PrimaryPhysician

Thissectionisoptional.Filloutthispartonlyifyouwishtonameyourprimaryphysiciantoday.

Nameofmyprimaryphysician:

Address: Phone:

IwantanyagentInamedinPart1totalkwiththisphysicianaboutmyhealthcare.IfthephysicianIhavenamedaboveisnotwilling,reasonablyavailableorabletocarryoutmywishes,IwanttheagentInamedinPart1totalkwiththephysicianlistedbelow:

Nameofphysician:

Address:Phone:

Ifyouwantyouragentorthosemakingdecisionsforyoutospeakwithanursepractitionerorphysicianassistantbeforemakingadecision,youmaycompletethefollowingsection:

Nameofnursepractitionerorphysicianassistant:

Address: Phone:

Part4–Donation ofBody,OrgansorTissuesatDeath

Thissectionisoptional.Filloutthispartonlyifyouwanttogivedirectionsaboutdonatingyourbody,organsortissuesafteryourdeath.

IdoNOTwishtodonateanyorgans,tissuesorparts.

------Ihavecheckedbelowmychoicesaboutdonatingmybody,organsortissuesafterdeath. IhavespokenwithmyfamilysothattheywillnotobjecttomywishesafterIdie.

Igivemybody. OR

Igiveanyneededorgans,tissuesorparts. OR

Igiveonlythefollowingorgans,tissues,orparts:

Mygiftisforthefollowingpurposes(youmaycheckanynumberofboxes):

Mygiftisfortransplantortherapyforanotherperson,tobechosenbasedongenerallyacceptedhealth

carestandards.

Mygiftisforresearchandeducation.Mypreference,ifany,istogivemybody,organs,ortissuestothefollowinghospital,medicalschool,orphysician:

Name

Address

IunderstandthatImayneedtocontactthehospital,medicalschool,orphysicianbeforeIdieinorderforthemtoacceptmybody,organsortissuesaftermydeath.

Part5–InstructionsAbout

FuneralandBurialArrangements

Thissectionisoptional.Filloutthispartonlyifyouwishtogivespecialinstructionsaboutyourfuneralorburialarrangementshere.

IhopethatmyfamilywillfollowmywishesafterIdieasnotedbelow.

Ichoose tohavecustodyandcontrolofmybodyaftermydeathwiththerighttodecideeverythingaboutmyfuneralandburial.

OR

Iwantmyfamilytoknowthesearemywishesabout:burial,cremation,funeral,ormemorialservice.(Fillin)

Ifyouplantodieathome,talkwithyourphysicianandfuneraldirectoraboutyourplans. Whenyoudie,yourfamilyoragentshouldcallyourphysicianandthefuneralhomeyouhavechosen. Thefuneralhomestaffwillpickupyourbodyfromyourhome.

Part6—Signing theForm

Ifyouhavefilledoutanypartofthisform,youmustsignanddatetheformonthispage.Youmustalsohavetwootheradultssignaswitnessesatthesametimeyousigntheform. Youragentcannotsignasawitness.YoudonotneedtohaveaNotaryPublicsignyourAdvanceDirectiveformtomakeitlegalinMaine. However,ifyoutravelorlivepartoftheyearout-of-state,itwouldbewisetohaveitsignedbyaNotary.Somestatesrequirethis. YoucanfindthisserviceunderNotaryPublicinthephonebook.MostbanksalsohaveNotariesPublicandwillusuallynotarizepapersforbankcustomerswhenasked. TheNotaryAcknowledgmentmaybedoneatanytimeafteryousignthisform.

Signanddatetheformhere:

Signyourname: Printyourname:

Date:

YourAddress:

Firstwitness:

Signature: Printyourname: Date: Secondwitness:

Signature: Printyourname: Date:

NotaryAcknowledgment.

Thenpersonallyappearedtheabovenamed

Address:

Address:

,knowntomeorwho

presentedsatisfactoryevidenceofhis/heridentity,andacknowledgedthisAdvanceDirectiveashis/herfreeactanddeedbeforeme.

Notarysignature:

Date:

Printedname: NotaryPublicStateof:CommissionExp.:

Makesuretotellpeople. Tellyourfamilymembers,physiciansandothersclosetoyouwhatyouhavedecided.Youshouldtalktotheagent(s)youhavechosentomakesurethattheyunderstandyourwishesandarewillingtocarrythemout. Giveacopyofthisformtoyourphysician,toanyplacewhereyougethealthcare,andtoanyagent(s)youhavechoseninPart1. Pleasebesuretolistthepeoplewhohavecopiesofthisformonthefrontpage.

Cancelingorchangingtheform.

Part1: Youmayendyouragent’srighttomakedecisionswhileyouarestillabletomakethosedecisionsbytelling

yourprimaryphysicianorputtingyourdecisioninwritingandattachingittothisform. Ifyouwanttonameanewagent,youmustputthatinstructioninwritingandsignitinfrontoftwowitnesseswhomustalsosigntheirnames.

Parts2-7:Youmaycancelanyotherpartofthisform,orchangeyourinstructionsintheotherpartsofthisformwhileyouarestillabletomakethosedecisions. Itisbesttodosoby(1)writingonthisform,(2)writingonanotherpieceofpaperandattachingittothisform,or(3)completinganewform. Anyofthosewrittenchangesshouldbesignedanddatedbyyou.

Part7—InstructionstoEmergency MedicalServices

(ambulance crews)aboutwhattodoifyourheartorbreathingstops.

Thissectionisoptional. Ifyoudonotwantambulancecrewstoreviveyouifyourheartorbreathingstops,youandyourphysician(ornursepractitionerorphysicianassistant)mustbothcompleteandsignthispart.

InstructionsforPart7:

•IfIstopbreathingormyheartstops,IdonotwanttheEmergencyMedicalServices(ambulancecrews)

totrytoreviveme. Myphysician(ornursepractitionerorphysicianassistant)andIhavediscussedthisandsignedthespecialformonthenextpage.Iunderstandthatthisdecisionwillnotpreventmefromreceivingotheremergencycare,orcomfortcarefromhealthcareworkersbeforeIdie.

•IunderstandthattheformgoesintoeffectwhenIhavesigneditANDitissignedbymyphysician(or

nursepractitionerorphysicianassistant).

•Iunderstandthatthisdirectivewillnotbefollowedunlessmyfamily,caretakerorIgivethesignedformonthenextpagetoEmergencyMedicalServices(ambulancecrews),andthatitissolelymyresponsibilitytomakesuretheyseeit.

•IunderstandthatIshouldcarrythesignedformwithmeunlessIwearhealthalertjewelry,suchasMedicAlert,thatalsotellspeoplethatIdonotwanttoberevivedifmyheartorbreathingstops(PleasecallMaineEmergencyMedicalServicesat207-626-3860toseeifthereareotherMaineEMSapprovedhealthalertjewelrycompanies).

•IunderstandthatifanyhealthcareproviderhasanydoubtsaboutwhatIwant,theywilltrytorestartmyheartorbreathing.

•IunderstandthatImayrevokethisdirectiveatanytimebydestroyingthisformandremovinganyMaineEMSapprovedDo-Not-Resuscitatejewelry. IcanalsotelltheambulancecrewsthatIhavechangedmymind.

•IunderstandthatshouldIchangemymind,itismyresponsibilitytotellmyphysician(ornursepractitionerorphysicianassistant)andotherpeoplewhohavecopiesofthesignedform.

•IfIwantmyagenttomakethisdecisionlater,myagentshouldtaketheformavailableat:ornursepractitionerorphysicianassistant)whenitistimetomakethedecision.

Ifyoucompleteandsignthissection,puttheoriginalinasafeplaceandbesuretogivecopiestoambulancecrews,yourfamily,yourcaregivers,andyourphysician.

DO-NOT-RESUSCITATE(DNR)DIRECTIVE

Thissectionisoptional.Ifyoudonotwantambulancecrewstoreviveyouifyourheartorbreathingstops,youandyourphysician(ornursepractitionerorphysicianassistant)mustcompleteandsignthisform.

FORPATIENTTOCOMPLETEafterconsultationwithhisorherhealthcareprovider:

IntheeventthatmyheartorbreathingstopsandIamunabletospeakformyself,I,

(printedname)directthatnoeffortsbetakentorestartmyheartorbreathingandthatEmergencyMedicalServices(ambulancecrews)ifnotified,honormydirective. Ihavecometothisdecisionafterconsideringmyconditionandprognosisandthepotentialrisks,burdensandbenefitsofrefusingeffortstorestartmyheartorbreathing.

IunderstandthatImaychangemymindatanytimebydestroyingthisformandremovinganyMaineEMSapprovedDo-Not-Resuscitatejewelry,suchasMedicAlert. Iwillalsotellmyphysician(ornursepractitionerorphysicianassistant)andothercaregiversifIchangemymind.

Iunderstandthatthisformisnotvaliduntilmyphysician(ornursepractitionerorphysicianassistant)

andIhavesignedit.

Iunderstandthatinahospital,nursinghome,hospiceorhomehealthsetting,federallawrequiresthatmyphysicianmustincludeaspecificDNRorderinmymedicalrecordorplanofcare,evenifwehavebothsignedthisform.

NoexpirationdateOR Expireson

PatientSignatureDateSigned

FORPHYSICIAN,PHYSICIANASSISTANTORNURSEPRACTITIONERTOCOMPLETE:

BymysignatureIaffirmthat:

(i)Aftermeetingwiththispatientanddiscussingthisdecision,Iamsatisfiedthatthepatientunderstandsthepotentialrisks,burdensandbenefitsofrefusingresuscitativeinterventionsinlightofthepatient’smedicalcondition;and(ii)IbelievethatthepatienthasmadeavoluntaryinformeddecisionaboutresuscitationandIagreetocomplywiththatdecision. Iwilltellanyhealthcareprovidersproviding

careundermyauthoritytocomplywiththisdecision.

Signatureandlicenselevel(MD,DO,PAorNP)DateSigned

PrintedNameTelephoneNumber

THISFORMISENDORSEDBYMAINEEMERGENCYMEDICALSERVICES