Maine Living Will Template
This Maine Living Will Template allows individuals to outline their healthcare preferences in the event that they are unable to communicate their wishes due to a terminal illness or incapacitation. It is designed in accordance with the Maine Health Care Advance Directive Act.
Part 1: Information of the Declaration Maker
Name: ___________________________________________________
Date of Birth: _________________________
Address: ___________________________________________________
City: ________________________ State: Maine Zip: ___________
Telephone: _____________________
Part 2: Appointment of Health Care Agent
This section allows you to name an individual as your health care agent, who will make decisions on your behalf if you are unable to do so.
Health Care Agent's Name: ________________________________________
Relationship to Declaration Maker: _________________________________
Address: ___________________________________________________________
City: ________________________ State: _________ Zip: _______________
Alternate Health Care Agent's Name: __________________________________
Relationship to Declaration Maker: _________________________________
Address: ___________________________________________________________
City: ________________________ State: _________ Zip: _______________
Part 3: Directions for Health Care
In this section, you can specify your preferences regarding the acceptance or refusal of medical treatment in scenarios involving a terminal condition, permanent unconsciousness, or other severe conditions.
- Life-Sustaining Treatment: ____ Accept ____ Decline
- Artificial Nutrition and Hydration: ____ Accept ____ Decline
- Pain Relief Preference: ___________________
- Other Instructions: _____________________________________________
Part 4: Organ and Tissue Donation
You may choose to make an anatomical gift by marking the appropriate option below:
- ____ I wish to donate any needed organs or tissues.
- ____ I wish to donate only the following organs or tissues: _____________________
- ____ I do not wish to make any anatomical gifts.
Part 5: Signature
This living will shall not be valid unless it is signed by the declaration maker or by another at the declaration maker's direction. It must also be witnessed by two (2) individuals not related to the declaration maker by blood or marriage and not entitled to any part of the declaration maker's estate.
Signature of Declaration Maker: __________________________ Date: ____________
Witness 1: _____________________________________________ Date: ____________
Witness 2: _____________________________________________ Date: ____________
Part 6: Acknowledgment
Acknowledgment by Notary Public or other authorized individual is required for this Maine Living Will to be legally binding.
Notarized by: __________________________________________ Date: ____________
Commission expires: ___________________________________