MaineHealthCare
AdvanceDirective Form
Youmayusethisformnowtotellyourphysicianandotherswhatmedicalcareyouwanttoreceiveifyoubecometoosickinthefuturetotellthemwhatyouwant. YoumaychoosetofilloutthewholeformoranypartoftheformandthensignanddatetheforminPart6.Thesearetheparts:
Part1 / Fillthisoutifyouwanttochoosesomeonetomakeallyourhealthcaredecisionsforyou,eitherrightawayorifyoubecometoosicktotellotherswhatyouwant. Thispersoniscalledyouragent.Part2 / Fillthisoutif: (1)youdidnotnameanagentinPart1andnowwanttochoosewhetheryouwantcertaintreatmentsor,(2)youdidnameanagentinPart1andwanttotellyouragentyourwishesaboutcertaintreatments,knowingthatyouragentmustfollowyourdirections.
Part3 / Fillthisoutifyouwanttogivethenameofyourprimaryphysician,physicianassistantornursepractitioner.
Part4 / Fillthisoutifyouwanttomakedecisionsaboutdonatingyourorgans,bodyortissuesafteryourdeath.
Part5 / Fillthisoutifyouwant:(1)tochoosesomeonetomakeallfuneralandburialdecisionsafteryourdeath,or(2)totellyourfamilyanywishesyouhaveaboutfuneralandburialdecisions.
Part6 / YoumustsignanddateyourAdvanceDirectiveformonthispage. Havetwowitnessessigntheformatthesametimeyousignit. Tellothersaboutyourdecisionsandgivecopiestoyourphysician,otherhealthcareproviders,familyandhospital.
Part7 / Ifyoudonotwishtoberevivedbyambulancecrewsshouldyourheartorbreathingstop,thenyouandyourphysician(ornursepractitionerorphysicianassistant)needtosignthisDoNotResuscitate(DNR)form.
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