Down East Community Hospital
11 Hospital Drive, Machias, ME 04654
Phone: 207.255.3356


Advanced Directive

ADVANCED DIRECTIVE
AND
DURABLE POWER OF ATTORNEY FOR HEALTH CARE

DECLARATION

I, __________________________________, being of sound mind, willfully and voluntarily make this declaration to be followed if I become without capacity or incompetent. This declaration reflects my firm and settled commitment regarding the forms of treatment for the circumstances indicated below.

I do /do not direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness.

I do / do not direct that treatment to be limited to measures to keep me comfortable and to relieve pain, including any pain that might occur by withholding or withdrawing life-sustaining treatment.

In addition, if I am in the conditions described above, I feel especially strong about the following forms of treatment:

I do / do not want cardiac resuscitation.
I do / do not want mechanical respiration.
I do / do not want tube feeding or any other invasive form of nutrition (food) or hydration (water).
I do / do not want blood or blood products.
I do / do not want any form of surgery or invasive diagnostic tests.
I do / do not want kidney dialysis.
I do / do not want antibiotics.
I do / do not want to donate my organs at my death.
I do / do not want to designate another person as my agent to make medical decisions for me when my doctor decides I am not able to make my own health care decisions.
I do/ do not want my agent to make health care decision for me right
away.

You have the right to cancel or replace this form at any time. Please inform each person and place you gave a copy to that you have cancelled this form and provide them with a copy of any new form you may fill out.
My Name (please print): ____________________________________

My Address: _____________________________________________

My Phone: _______________________________________________

My Birthdate: ____________________________________________

My Primary Doctor: _______________________________________

Doctors Phone: ___________________________________________

I choose the following person as my agent to make health care decisions for me:

Name: _________________________________________________

Title or Relationship: _____________________________________

Address: ________________________________________________

Home Phone: ______________ Work Phone: _______________

If I cancel by first choice for agent or if my first choice is not able to be my agent, my second choice for agent is listed here:

Name: ________________________________________________

Title or Relationship: _____________________________________

Address: _______________________________________________

Home Phone: ______________ Work Phone: ______________

We suggest that you discuss this document with your family physician, your agent(s), and family members to ensure that they understand your wishes and are willing to carry them out. Make sure to give a copy to all of your health care providers and your local hospital.

Copies of this form have been given to the following:

____________________________________________

____________________________________________

____________________________________________

____________________________________________

OTHER WISHES

Relief from pain: I have checked below my choices about pain relief:

 I want treatment for relief of pain or discomfort to be given at all times, even if it shortens the time until my death or makes me unconscious or unable to do other things.

 These are my wishes about relief or pain or discomfort:

____________________________________________________

____________________________________________________

____________________________________________________

Any other wishes that you have should be written here.

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

If you have filled out this form, you must sign and date it. You must also have two (2) other people sign as witnesses. You do not need to have an Advanced Directive form notarized to make it legal in Maine. However, if you plan to travel out of the state or reside out of state seasonally, it is recommended that you obtain a notarization of this document.

Sign and date the form here:

Sign your name: ___________________________________________

Print your name here: _______________________________________

Address: _________________________________________________

Date: ___________________

First Witness:

Sign your name: ___________________________________________

Print your name here: _______________________________________

Address: _________________________________________________

Date: ___________________

Second Witness:

Sign your name: ___________________________________________

Print your name here: _______________________________________

Address: _________________________________________________

Date: ___________________

Notary Acknowledgment; Then personally appeared the above named ____________________ to me well know and acknowledged this Advanced Directive, including power of attorney for healthcare, and his/her free act and deed before me.

Date: ______ State of: _______________ Commission Exp: ___________

Print Name: _____________________ Signature: ___________________