Fillable Maine Health Care Advance Directive Form (Page 6 of 14) in pdf

Maine Health Care Advance Directive Form Page 6

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Part 2 – Special Instructions

Instructions if you did not name an agent in Part 1:

If you did not name an agent in Part 1, you should fill out this Part to state what you want for care if you

become too sick to make your choices known.

Instructions if you did name an agent in Part 1:

If you named an agent in Part 1, you do not have to fill out this part of the form. If you want your agent to

make all of your health care decisions, DO NOT fill out this part of the form. Your agent will make decisions

in your best interests, including decisions to refuse treatment. However, you may fill out this part if you want to

give special directions to your agent about your wishes, such as when you are near death, in a permanent coma

or no longer able to make your own decisions. You may also cross out or add words. It is best if you put your

initials and date next to any changes you make so everyone knows the changes were your decision. If you

complete this part, your physician and others will follow these instructions and your agent cannot make a

different decision. You may also write your wishes on another piece of paper, sign it, date it, and keep it with

this form.

Life-Sustaining Treatment Choices:

You may check one of the two boxes below to show your choice about getting treatments that would keep you

alive:

Choice not to be kept alive

Choice to be kept alive

I do not want treatment to keep me alive if my

I want to be kept alive as long as possible

physician decides that either of the following is true;

within the limits of generally accepted health

care standards, even if my condition is

(i) I have an illness that will not get better, cannot

terminal or I am in a persistent vegetative

be cured, and will result in my death quite soon

state.

(sometimes referred to as a terminal condition),

(ii) I am no longer aware (unconscious) and it is very

likely that I will never be conscious again (sometimes

referred to as a persistent vegetative state).

Page 6 of 14

Revised February 2008

Maine Health Care Advance Directive Form Page 6

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