Maine Revised Statutes Title 18-C Sec. 5-805 – Optional form
Current as of: 2023 | Check for updates
|
Other versions
Terms Used In Maine Revised Statutes Title 18-C Sec. 5-805
- Advance health care directive: means an individual instruction from, or a power of attorney for health care by, an individual with capacity. See Maine Revised Statutes Title 18-C Sec. 5-802
- Agent: means an individual with capacity designated in a power of attorney for health care to make a health care decision for the individual granting the power. See Maine Revised Statutes Title 18-C Sec. 5-802
- Capacity: means the ability to have a basic understanding of the diagnosed condition and to understand the significant benefits, risks and alternatives to the proposed health care and the consequences of forgoing the proposed treatment, the ability to make and communicate a health care decision and the ability to understand the consequences of designating an agent or surrogate to make health care decisions. See Maine Revised Statutes Title 18-C Sec. 5-802
- Gift: A voluntary transfer or conveyance of property without consideration, or for less than full and adequate consideration based on fair market value.
- Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
- Guardian: means a judicially appointed guardian or conservator having authority to make a health care decision for an individual. See Maine Revised Statutes Title 18-C Sec. 5-802
- Health care: means any care, treatment, service or procedure to maintain, diagnose or otherwise affect an individual's physical or mental condition. See Maine Revised Statutes Title 18-C Sec. 5-802
- Health care decision: means a decision made by an individual with capacity or by the individual's agent, guardian or surrogate regarding the individual's health care, including:
A. See Maine Revised Statutes Title 18-C Sec. 5-802Health care institution: means an institution, facility or agency licensed, certified or otherwise authorized or permitted by law to provide health care in the ordinary course of business. See Maine Revised Statutes Title 18-C Sec. 5-802 Life-sustaining treatment: means any medical procedure or intervention that, when administered to a person without capacity and in either a terminal condition or a persistent vegetative state, will serve only to prolong the process of dying. See Maine Revised Statutes Title 18-C Sec. 5-802 Obligation: An order placed, contract awarded, service received, or similar transaction during a given period that will require payments during the same or a future period. Person: means an individual, corporation, business trust, estate, trust, partnership, association, joint venture, government, governmental subdivision, agency or instrumentality or any other legal or commercial entity. See Maine Revised Statutes Title 18-C Sec. 5-802 Physician: means an individual authorized to practice medicine under Title 32. See Maine Revised Statutes Title 18-C Sec. 5-802 Power of attorney: A written instrument which authorizes one person to act as another's agent or attorney. The power of attorney may be for a definite, specific act, or it may be general in nature. The terms of the written power of attorney may specify when it will expire. If not, the power of attorney usually expires when the person granting it dies. Source: OCC Power of attorney for health care: means the designation of an agent with capacity to make health care decisions for the individual granting the power. See Maine Revised Statutes Title 18-C Sec. 5-802 Primary physician: means a physician designated by an individual with capacity or by the individual's agent, guardian or surrogate to have primary responsibility for the individual's health care or, in the absence of a designation or if the designated physician is not reasonably available, a physician who undertakes the responsibility. See Maine Revised Statutes Title 18-C Sec. 5-802 Reasonably available: means readily able to be contacted without undue effort and willing and able to act in a timely manner considering the urgency of the patient's health care needs. See Maine Revised Statutes Title 18-C Sec. 5-802 Sign: means , with present intent to authenticate or adopt a record:
A. See Maine Revised Statutes Title 18-C Sec. 5-102State: includes an Indian tribe or band recognized by federal law or formally acknowledged by a state. See Maine Revised Statutes Title 18-C Sec. 5-102
The following form may, but need not, be used to create an advance health care directive. The other sections of this Part govern the effect of this or any other writing used to create an advance health care directive. An individual with capacity may complete or modify all or any part of the following form.
ADVANCE HEALTH CARE DIRECTIVE
Explanation
[PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
You have the right to give instructions about your own health care. You also have the right to name someone else to make health care decisions for you. This form lets you do either or both of these things. It also lets you express your wishes regarding donation of organs and the designation of your primary physician. If you use this form, you may complete or modify all or any part of it. You are free to use a different form. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
Part 1 of this form is a power of attorney for health care. Part 1 lets you name another individual as agent to make health care decisions for you if you become incapable of making your own decisions or if you want someone else to make those decisions for you now even though you are still capable. You may also name an alternate agent to act for you if your first choice is not willing, able or reasonably available to make decisions for you. Unless related to you, your agent may not be an owner, operator or employee of a residential long-term health care institution at which you are receiving care. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
Unless the form you sign limits the authority of your agent, your agent may make all health care decisions for you. This form has a place for you to limit the authority of your agent. You need not limit the authority of your agent if you wish to rely on your agent for all health care decisions that may have to be made. If you choose not to limit the authority of your agent, your agent will have the right to: [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
(1) Consent or refuse consent to any care, treatment, service or procedure to maintain, diagnose or otherwise affect a physical or mental condition; [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
(2) Select or discharge health care providers and institutions; [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
(3) Approve or disapprove diagnostic tests, surgical procedures, programs of medication and orders not to resuscitate; and [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
(4) Direct the provision, withholding or withdrawal of artificial nutrition and hydration and all other forms of health care, including life-sustaining treatment. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
Part 2 of this form lets you give specific instructions about any aspect of your health care. Choices are provided for you to express your wishes regarding the provision, withholding or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and hydration, as well as the provision of pain relief. Space is also provided for you to add to the choices you have made or for you to write out any additional wishes. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
Part 3 of this form lets you express an intention to donate your bodily organs and tissues following your death. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
Part 4 of this form lets you designate a physician to have primary responsibility for your health care. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
After completing this form, sign and date the form at the end. You must have 2 other individuals sign as witnesses. Give a copy of the signed and completed form to your physician, to any other health care providers you may have, to any health care institution at which you are receiving care and to any health care agents you have named. You should talk to the person you have named as agent to make sure that he or she understands your wishes and is willing to take the responsibility. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
You have the right to revoke this advance health care directive or replace this form at any time. [PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
PART 1
POWER OF ATTORNEY FOR HEALTH CARE
(1) DESIGNATION OF AGENT: I designate the following individual as my agent to make health care decisions for me:
………………………………………………………………………………………………………………………..
(name of individual you choose as agent)
………………………………………………………………………………………………………………………..
(address) (city) (state) (zip code)
………………………………………………………………………………………………………………………..
(home phone) (work phone)
OPTIONAL: If I revoke my agent’s authority or if my agent is not willing, able or reasonably available to make a health care decision for me, I designate as my first alternate agent:
…………………………………………………………………………………………………………………….
(name of individual you choose as first alternate agent)
……………………………………………………………………………………………………………………..
(address) (city) (state) (zip code)
…………………………………………………………………………………………………………………..
(home phone) (work phone)
OPTIONAL: If I revoke the authority of my agent and first alternate agent or if neither is willing, able or reasonably available to make a health care decision for me, I designate as my second alternate agent:
……………………………………………………………………………………………………………………..
(name of individual you choose as second alternate agent)
……………………………………………………………………………………………………………………
(address) (city) (state) (zip code)
……………………………………………………………………………………………………………………..
(home phone) (work phone)
(2) AGENT’S AUTHORITY: My agent is authorized to make all health care decisions for me, including decisions to provide, withhold or withdraw artificial nutrition and hydration and all other forms of health care to keep me alive, except as I state here:
……………………………………………………………………………………………………………………….
………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………
(Add additional sheets if needed.)
(3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE: My agent’s authority becomes effective when my primary physician determines that I am unable to make my own health care decisions unless I mark the following box. If I mark this box [ ], my agent’s authority to make health care decisions for me takes effect immediately.
(4) AGENT’S OBLIGATION: My agent shall make health care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health care decisions for me in accordance with what my agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.
(5) NOMINATION OF GUARDIAN: If a guardian of my person needs to be appointed for me by a court, I nominate the agent designated in this form. If that agent is not willing, able or reasonably available to act as guardian, I nominate the alternate agents whom I have named, in the order designated.
[PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
PART 2
INSTRUCTIONS FOR HEALTH CARE
If you are satisfied to allow your agent to determine what is best for you in making end-of-life decisions, you need not fill out this part of the form. If you do fill out this part of the form, you may strike any wording you do not want.
(6) END-OF-LIFE DECISIONS: I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the choice I have marked below:
[ ] (a) Choice Not To Prolong Life
I do not want my life to be prolonged if (i) I have an incurable and irreversible condition that will result in my death within a relatively short time, (ii) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness or (iii) the likely risks and burdens of treatment would outweigh the expected benefits, OR
[ ] (b) Choice To Prolong Life
I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.
(7) ARTIFICIAL NUTRITION AND HYDRATION: Artificial nutrition and hydration must be provided, withheld or withdrawn in accordance with the choice I have made in paragraph (6) unless I mark the following box. If I mark this box [ ], artificial nutrition and hydration must be provided regardless of my condition and regardless of the choice I have made in paragraph (6).
(8) RELIEF FROM PAIN: Except as I state in the following space, I direct that treatment for alleviation of pain or discomfort be provided at all times, even if it hastens my death:
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
(9) OTHER WISHES: (If you do not agree with any of the optional choices above and wish to write your own, or if you wish to add to the instructions you have given above, you may do so here.) I direct that:
………………………………………………………………………………………………………………………..
………………………………………………………………………………………………………………………..
(Add additional sheets if needed)
[PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
PART 3
DONATION OF ORGANS AT DEATH
(OPTIONAL)
(10) UPON MY DEATH: (mark applicable box)
[ ] (a) I give any needed organs, tissues or parts, OR
[ ] (b) I give the following organs, tissues or parts only:
………………………………………………………………………………………………………….
(c) My gift is for the following purposes: (strike any of the following you do not want)
(i) Transplant
(ii) Therapy
(iii) Research
(iv) Education
[PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
PART 4
PRIMARY PHYSICIAN
(OPTIONAL)
DESIGNATION OF PRIMARY PHYSICIAN
(11) I designate the following physician as my primary physician:
……………………………………………………………………………………………………………………..
(name of physician)
……………………………………………………………………………………………………………………
(address) (city) (state) (zip code)
……………………………………………………………………………………………………………………
(phone)
OPTIONAL: If the physician I have designated above is not willing, able or reasonably available to act as my primary physician, I designate the following physician as my primary physician:
…………………………………………………………………………………………………………………..
(name of physician)
……………………………………………………………………………………………………………………
(address) (city) (state) (zip code)
……………………………………………………………………………………………………………………
(phone)
(12) EFFECT OF COPY: A copy of this form has the same effect as the original.
(13) SIGNATURES: Sign and date the form here:
……………………………………………………………………………………………………………………
(date) (sign your name)
…………………………………………………………………………………………………………………..
(address) (print your name)
………………………………………………………………………………………………………………….
(city) (state)
SIGNATURES OF WITNESSES:
First witness 2nd witness
…………………………………………………………………………………………………………………..
(print name) (print name)
………………………………………………………………………………………………………………….
(address) (address)
………………………………………………………………………………………………………………..
(city) (state) (city) (state)
……………………………………………………………………………………………………………….
(signature of witness) (signature of witness)
………………………………………………………………………………………………………………..
(date) (date)
[PL 2017, c. 402, Pt. A, §2 (NEW); PL 2019, c. 417, Pt. B, §14 (AFF).]
SECTION HISTORY
PL 2017, c. 402, Pt. A, §2 (NEW). PL 2017, c. 402, Pt. F, §1 (AFF). PL 2019, c. 417, Pt. B, §14 (AFF).