Official Living Will Document for Maine

Maine Living Will Template

This Living Will was drafted in accordance with the Maine Health Care Advance Directive Act, allowing individuals residing in Maine to indicate their wishes regarding medical treatment in circumstances where they are unable to communicate their desires directly.

Personal Information

• Full Name: ___________________________
• Date of Birth: ___________________________
• Address: ___________________________, ___________________________, ME, _____
• Phone Number: ___________________________

Health Care Decisions

In the event that I am unable to make or communicate my health care decisions, I wish the following preferences to guide those who are making decisions on my behalf:

1. Life-Sustaining Treatment:
   • If I am in a terminal condition, I do / do not want treatments whose primary purpose is to prolong my life, including but not limited to: mechanical ventilation, tube feeding, and other high-intensity treatments.
   • If I am in a state of permanent unconsciousness, I do / do not want treatments that may prolong life without the chance of recovery.
2. Pain Relief:
   • I wish to receive medication or other interventions necessary to relieve pain or discomfort, even if such treatments may hasten my death.
3. Other Preferences:
   • My additional wishes regarding my health care (e.g., preferred hospital, religious or spiritual care preferences, funeral arrangements): __________________________________________________________________________________________

Health Care Agent

I designate the following individual as my Health Care Agent to make health care decisions for me when I cannot make them for myself. This designation revokes any previous health care agent designation.

• Name: ___________________________
• Relationship: ___________________________
• Primary Phone: ___________________________
• Alternate Phone: ___________________________

Alternate Health Care Agent

If my primary Health Care Agent is not willing, able, or reasonably available to make decisions for me, I designate the following individual as my alternate Health Care Agent.

• Name: ___________________________
• Relationship: ___________________________
• Primary Phone: ___________________________
• Alternate Phone: ___________________________

Signatures

This Living Will shall not be in effect until it is signed. By my signature below, I indicate that I understand the purpose and effect of this document.

_____________________________________
Signature of Declarant
Date: _____________________

_____________________________________
Signature of Witness #1
Date: _____________________

_____________________________________
Signature of Witness #2
Date: _____________________