Maine Health Care Advance Directive Form Page 7
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14Life-Sustaining Treatment Choices:
You may also check one of the two boxes below to show your choice about treatment that would keep you alive
if, in the future, you have late stage Alzheimer’s disease or other severe dementia. These choices will not limit
the authority under state law for your agent, surrogate, guardian or physician to make treatment choices if you
are unable to make your own decisions and are not in late stage Alzheimer’s disease or other severe dementia.
Choice not to be kept alive
Choice to be kept alive
If my physician and a second physician decide that I am
I want treatment to keep me alive as long as
in the late stage of Alzheimer’s disease* or other severe
possible within the limits of generally accepted
dementia, I do not want treatment to keep me alive.
health care standards, even if my physician and
a second physician decide that I am in the late
stage of Alzheimer’s disease or other severe
dementia.
* Only a physician can determine that someone is in the late stage of Alzheimer’s disease. People in the late
stages of Alzheimer’s disease generally have a number of the following characteristics: loss of the ability to
respond to their environment; loss of the ability to speak; loss of the ability to control movement; loss of the
capacity for recognizable speech, although words or phrases may occasionally be uttered; needing help with
eating and toileting; general incontinence of urine; loss of the ability to walk without assistance, then the ability
to sit without support, then the ability to smile, and the ability to hold their head up; reflexes become abnormal;
muscles grow rigid; and swallowing is impaired.
Tube Feeding: You may check one of the two boxes below to show your choice about tube feeding or having
water and nutrition fed into your body through an IV or tube (artificial nutrition and hydration):
Artificial nutrition and hydration should not
Artificial nutrition and hydration should be
be given, or should be stopped, based on the
given regardless of my condition.
other life-sustaining treatment choices I made
about keeping me alive on Pages 6 and 7.
Page 7 of 14
Revised February 2008
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