**HEALTHCARE POWER OF ATTORNEY
(State of Maine)**
[// GUIDANCE: Replace every bracketed placeholder before execution. Delete guidance comments after customization.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Appointment of Health-Care Agent
3.2 Scope of Authority
3.3 End-of-Life Instructions
3.4 HIPAA Authorization
3.5 Nomination of Guardian or Conservator - Representations & Warranties
- Covenants & Restrictions (Agent Duties)
- Default & Remedies
- Risk Allocation
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
1.1 Title.
Healthcare Power of Attorney (Advance Health-Care Directive) made pursuant to the Maine Uniform Health Care Decisions Act, 18-C M.R.S. art. 5, pt. 8 (the “Act”).
1.2 Parties.
(a) “Principal”: [PRINCIPAL FULL LEGAL NAME], residing at [ADDRESS].
(b) “Primary Agent”: [AGENT FULL LEGAL NAME], residing at [ADDRESS].
(c) “First Successor Agent” (optional): [SUCCESSOR AGENT NAME], residing at [ADDRESS].
(d) “Second Successor Agent” (optional): [SECOND SUCCESSOR NAME], residing at [ADDRESS].
1.3 Effective Date.
This instrument becomes effective upon execution and remains operational only during any period in which the Principal, in the judgment of the attending physician or advanced-practice provider, lacks capacity to make or communicate health-care decisions, unless an earlier or later triggering date is specified in Section 3.1(d).
1.4 Governing Law & Forum.
This instrument shall be governed by the health-care laws of the State of Maine. The Maine Probate Court for the county in which the Principal resides has exclusive jurisdiction over any proceeding arising hereunder.
2. DEFINITIONS
For purposes of this instrument, capitalized terms have the meanings set forth below. Defined terms appear in alphabetical order.
“Act” – The Maine Uniform Health Care Decisions Act, 18-C M.R.S. art. 5, pt. 8, as amended.
“Agent” – The Primary Agent, or if the Primary Agent is unable or unwilling to serve, the next-listed Successor Agent who is willing and able to act.
“Good Faith” – Honesty in fact in the conduct of the transaction concerned.
“Health Care” – Any care, treatment, service, or procedure to maintain, diagnose, or otherwise affect an individual’s physical or mental condition.
“HIPAA” – The Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, and its implementing regulations at 45 C.F.R. pts. 160 & 164.
“Life-Sustaining Treatment” – Any medical intervention that serves only to prolong the process of dying and where, in reasonable medical judgment, death is imminent were such intervention withheld or withdrawn.
[// GUIDANCE: Add additional defined terms as necessary for specialized instructions (e.g., “Palliative Care,” “Artificial Nutrition and Hydration”).]
3. OPERATIVE PROVISIONS
3.1 Appointment of Health-Care Agent
(a) The Principal hereby designates the Agent to make any and all Health-Care decisions on the Principal’s behalf when the Principal lacks capacity, subject to the limitations expressly stated herein.
(b) Successor hierarchy. If the Primary Agent is unavailable, unwilling, or lacks capacity, decision-making authority passes to the First Successor Agent; thereafter to the Second Successor Agent.
(c) Co-Agents. Unless expressly stated, Agents shall serve [choose one: “serially” / “jointly and severally”].
(d) Alternate Trigger (optional). [INSERT if the Principal wishes the power to be effective immediately or from a specified future date.]
3.2 Scope of Authority
Subject to Section 3.3, the Agent may in Good Faith:
1. Consent to, refuse, or withdraw any Health Care, including diagnostic tests, surgical procedures, medication regimens, and mental-health treatment;
2. Admit or discharge the Principal from any hospital, nursing home, residential facility, or hospice;
3. Hire and fire medical or personal-care personnel;
4. Access and disclose medical records pursuant to Section 3.4;
5. Authorize autopsy and disposition of remains, including organ and tissue donation, if consistent with the Principal’s known wishes or best interests;
6. Execute all documents, releases, or waivers necessary to implement the foregoing decisions.
3.3 End-of-Life Instructions
(a) Philosophy of Care: [e.g., “I desire all medically appropriate treatment that offers a reasonable expectation of recovery to a meaningful quality of life.”]
(b) Life-Sustaining Treatment: [select one]
i. I direct that Life-Sustaining Treatment be continued notwithstanding prognosis.
ii. I direct that Life-Sustaining Treatment be withheld or withdrawn if I am in an end-stage or permanently unconscious condition.
(c) Artificial Nutrition & Hydration: [select one]
i. Provide regardless of prognosis.
ii. Provide only if it will significantly improve comfort or recovery.
iii. Do not provide if death is imminent.
(d) Pain Management: Administer medication in doses and by routes necessary to alleviate pain or distress, even if such medication may hasten death.
(e) Do-Not-Resuscitate Order: [Yes/No]
(f) Organ & Tissue Donation: [Yes/No; specify limitations]
[// GUIDANCE: Maine law recognizes a written statement of the Principal’s medical treatment preferences as controlling. Insert any religious or moral directives here.]
3.4 HIPAA Authorization
(a) The Principal authorizes any “covered entity” or “business associate” (as those terms are defined under HIPAA) to disclose the Principal’s “protected health information” to the Agent to the same extent as the Principal could.
(b) This authorization is intended to be a valid “authorization” under 45 C.F.R. § 164.508 and survives the Principal’s death to the extent Health-Care decisions remain to be made.
(c) Redisclosure. The Agent may redisclose such information as necessary to carry out authorized decisions, recognizing that the information may no longer be protected by HIPAA once released.
3.5 Nomination of Guardian or Conservator
If a court of competent jurisdiction determines that a guardian or conservator is necessary, the Principal nominates the Agent, in the order of succession established above, to serve in that fiduciary role.
4. REPRESENTATIONS & WARRANTIES
4.1 Principal’s Capacity. The Principal affirms that, as of the Execution Date, the Principal is of sound mind, at least 18 years of age, and under no constraint or undue influence.
4.2 Agent Qualifications. Each person named as Agent represents that he or she (i) is at least 18 years old, (ii) is not currently employed by, or under contract with, any residential long-term-care facility in which the Principal resides (unless related by blood, marriage, or adoption), and (iii) is willing and able to serve.
5. COVENANTS & RESTRICTIONS (AGENT DUTIES)
5.1 Standard of Conduct. The Agent shall (i) act in Good Faith, (ii) consult available medical professionals, (iii) follow the Principal’s expressed wishes and, if unknown, the Principal’s best interests, and (iv) avoid conflicts of interest.
5.2 Record-Keeping. Upon request of any interested person defined in the Act, the Agent shall provide a written summary of decisions made and the rationale therefor, excluding confidential data where disclosure is prohibited by law.
5.3 Delegation. The Agent may not delegate decision-making authority except as reasonably necessary during brief periods of unavailability and only to persons meeting statutory eligibility.
6. DEFAULT & REMEDIES
6.1 Revocation by Principal. The Principal may revoke this instrument or any Agent’s authority at any time and in any manner that communicates intent to revoke.
6.2 Removal of Agent. Any interested person may petition the Maine Probate Court for removal of an Agent who is acting outside the scope of authority or in material breach of section 5.
6.3 Successor Activation. Upon removal, death, resignation, or incapacity of an Agent, authority passes automatically to the next listed Successor Agent.
6.4 Injunctive Relief. In view of the time-sensitive nature of Health-Care decisions, any court of competent jurisdiction may grant temporary or permanent injunctive relief to enforce or preserve the Principal’s directives.
7. RISK ALLOCATION
7.1 Indemnification. The Principal agrees to indemnify and hold harmless any Agent from liability for actions taken in Good Faith pursuant to this instrument, except for willful misconduct or gross negligence.
7.2 Limitation of Liability. No Agent shall be liable for monetary damages beyond those proximately caused by the Agent’s bad faith, willful misconduct, or gross negligence.
7.3 Reliance by Third Parties. Any third party may rely conclusively on the validity of this instrument and the authority of the Agent unless the third party has actual knowledge of its revocation or invalidity.
8. DISPUTE RESOLUTION
8.1 Governing Law. This instrument and all disputes arising hereunder shall be governed by the laws of the State of Maine, without regard to conflict-of-laws principles.
8.2 Forum Selection. The parties consent to exclusive jurisdiction and venue in the Maine Probate Court of [COUNTY] County.
8.3 Arbitration; Jury Waiver. Arbitration is expressly not available. No provision herein constitutes a waiver of any constitutional right to a jury trial.
9. GENERAL PROVISIONS
9.1 Amendment & Waiver. Any amendment must (a) be in writing, (b) executed with the same formalities as this instrument, and (c) clearly reference the section(s) amended. Waiver of any provision does not constitute waiver of any other.
9.2 Assignment. The authority granted is personal to the Agent and may not be assigned.
9.3 Severability. If any provision is held invalid or unenforceable, the remaining provisions shall nevertheless be given full force and effect, and the invalid provision shall be reformed to the minimum extent necessary to effectuate the Principal’s intent.
9.4 Integration. This document constitutes the entire Healthcare Power of Attorney and supersedes all prior inconsistent directives.
9.5 Counterparts; Electronic Signatures. This instrument may be executed in counterparts, each of which is deemed an original, and by electronic or digital signature to the fullest extent permitted under Maine law.
10. EXECUTION BLOCK
10.1 Principal’s Signature
I, [PRINCIPAL FULL LEGAL NAME], declare that I am signing this Healthcare Power of Attorney willingly, that I understand its consequences, and that I am at least 18 years of age and of sound mind.
Date: [DATE]
Signature: ______
Printed Name: _________
10.2 Witness Attestation (Choose either Sub-Section A or Sub-Section B)
(A) Two-Witness Option
We, the undersigned witnesses, affirm that (i) the Principal signed or acknowledged this Healthcare Power of Attorney in our presence; (ii) the Principal appears to be of sound mind and under no duress; and (iii) neither of us is the Agent, Successor Agent, or directly responsible for the Principal’s medical care.
-
Witness Signature: _____ Date: _
Printed Name & Address: _________ -
Witness Signature: _____ Date: _
Printed Name & Address: _________
(B) Notary Option
State of Maine
County of [COUNTY]
On [DATE], before me, the undersigned Notary Public, personally appeared [PRINCIPAL NAME], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that he or she executed the same for the purposes therein contained.
Notary Public Signature: ______
Printed Name: ______
My Commission Expires: _______
Seal: ☐
10.3 Agent’s Acceptance
I, [AGENT NAME], accept the appointment as Health-Care Agent and understand my duties under this instrument and Maine law.
Signature: ____ Date: _
Printed Name: _________
[Repeat acceptance blocks for each Successor Agent.]
[// GUIDANCE: File the executed original in a safe but accessible location. Provide copies to all Agents, physicians, and medical facilities. Review annually or upon major life changes.]