Maine Health Care Advance Directive Form Page 13
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14Part 7—Instructions to Emergency Medical Services
(ambulance crews) about what to do if your heart or breathing stops.
This section is optional. If you do not want ambulance crews to revive you if your heart or breathing stops,
you and your physician (or nurse practitioner or physician assistant) must both complete and sign this part.
Instructions for Part 7:
•
If I stop breathing or my heart stops, I do not want the Emergency Medical Services (ambulance crews)
to try to revive me. My physician (or nurse practitioner or physician assistant) and I have discussed
this and signed the special form on the next page. I understand that this decision will not prevent me
from receiving other emergency care, or comfort care from health care workers before I die.
•
I understand that the form goes into effect when I have signed it AND it is signed by my physician (or
nurse practitioner or physician assistant).
•
I understand that this directive will not be followed unless my family, caretaker or I give the signed
form on the next page to Emergency Medical Services (ambulance crews), and that it is solely my
responsibility to make sure they see it.
•
I understand that I should carry the signed form with me unless I wear health alert jewelry, such as
MedicAlert, that also tells people that I do not want to be revived if my heart or breathing stops (Please
call Maine Emergency Medical Services at 207-626-3860 to see if there are other Maine EMS approved
health alert jewelry companies).
•
I understand that if any health care provider has any doubts about what I want, they will try to restart
my heart or breathing.
•
I understand that I may revoke this directive at any time by destroying this form and removing any
Maine EMS approved Do-Not-Resuscitate jewelry. I can also tell the ambulance crews that I have
changed my mind.
•
I understand that should I change my mind, it is my responsibility to tell my physician (or nurse
practitioner or physician assistant) and other people who have copies of the signed form.
•
If I want my agent to make this decision later, my agent should take the form available at:
to my physician (or nurse practitioner or physician assistant) when it is
time to make the decision.
If you complete and sign this section, put the original in a safe place and be sure to give copies to
ambulance crews, your family, your caregivers, and your physician.
Page 13 of 14
Revised February 2008
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