**STATE OF MAINE

ADVANCE HEALTH-CARE DIRECTIVE & DURABLE POWER OF ATTORNEY FOR HEALTH CARE**
(“Living Will / Advance Directive”)

[// GUIDANCE: This template is drafted to comply with the Maine Uniform Health-Care Decisions Act and current best-practice standards. Practitioners should confirm that no statutory amendments have occurred since the date of use.]

Effective Date: [DATE]
Principal: [LEGAL NAME OF PRINCIPAL] (“Principal”)
Principal’s Address: [STREET, CITY, ME ZIP]
Date of Birth / Last 4 SSN: [DOB] / [XXX-XX-____]

TABLE OF CONTENTS

1. Recitals
2. Definitions
3. Appointment of Health-Care Agent
4. Alternate Agents
5. General Grant of Authority & Scope of Agency
6. Statement of Health-Care Instructions
   6.1 Life-Sustaining Treatment
   6.2 Artificial Nutrition & Hydration
   6.3 Pain Management & Palliative Care
   6.4 End-of-Life Location Preference
   6.5 Mental-Health Treatment Instructions
   6.6 Anatomical Gifts & Organ Donation
7. HIPAA Authorization
8. Nomination of Guardian or Conservator
9. Reliance, Immunities & Good-Faith Liability Cap
10. Revocation & Amendment
11. Copies; Electronic & Photographic Records
12. General Provisions
13. Execution & Acknowledgment
14. Witness Attestation
15. Optional Notary Acknowledgment

1. RECITALS

A. The Principal is an adult of sound mind and capacity and desires to execute a legally enforceable advance directive pursuant to Maine law to (i) appoint an agent to make health-care decisions when the Principal lacks capacity, and (ii) set forth clear instructions regarding health-care preferences.
B. This Directive is intended to be honored by all health-care providers, facilities, agents, courts, and third parties acting in good faith reliance hereon.

2. DEFINITIONS

For purposes of this Directive, capitalized terms have the meanings set forth below:

“Advance Directive” or “Directive” means this written instrument executed by the Principal pursuant to Maine law that contains both a durable power of attorney for health care and individual health-care instructions.

“Agent” means the person designated in Section 3 to make health-care decisions for the Principal when the Principal is determined to lack capacity.

“Capacity” means an individual’s ability to understand the significant benefits, risks, and alternatives to proposed health-care and to make and communicate a health-care decision.

“Health-Care Decision” means a decision made by the Principal or the Agent regarding the Principal’s health-care, including consent, refusal of consent, or withdrawal of consent to any care, treatment, service, or procedure.

“Life-Sustaining Treatment” means any medical procedure or intervention that, in the judgment of the attending physician or provider, when applied to the Principal would serve only to prolong the dying process.

“Primary Physician” means the physician designated by the Principal or determined pursuant to statute to have primary responsibility for the Principal’s health-care.

[// GUIDANCE: Insert additional definitions as necessary for specialized medical preferences.]

3. APPOINTMENT OF HEALTH-CARE AGENT

3.1 Designation. The Principal hereby appoints:
• Name: [NAME OF FIRST AGENT]
• Address: [ADDRESS]
• Telephone: [PRIMARY PHONE]
to act as Agent with full authority to make any and all Health-Care Decisions for the Principal consistent with Section 5, subject to the limitations expressed herein.

3.2 Acceptance. By signing in Section 13, the Agent accepts the fiduciary duties imposed by law and this Directive.

4. ALTERNATE AGENTS

If the Agent named above is unavailable, unwilling, or unable to act, the following individuals shall serve successively as Alternate Agent(s) in the order listed:

a. First Alternate Agent: [NAME / CONTACT INFO]
b. Second Alternate Agent: [NAME / CONTACT INFO]

5. GENERAL GRANT OF AUTHORITY & SCOPE OF AGENCY

5.1 Scope. The Agent’s authority becomes effective upon a written or oral determination by the Principal’s primary physician (or other statutorily authorized practitioner) that the Principal lacks Capacity.

5.2 Decisions Included. Without limiting the foregoing, the Agent is authorized to:
a. Provide, withhold, or withdraw Life-Sustaining Treatment;
b. Consent to or withdraw artificial nutrition or hydration;
c. Admit or discharge the Principal from any health-care facility;
d. Request, review, and receive any medical or insurance information;
e. Hire and discharge medical personnel;
f. Authorize autopsy, organ donation, or disposition of remains; and
g. Pursue any administrative or judicial remedy necessary to enforce the Principal’s wishes.

5.3 Limitations. [INSERT ANY SPECIFIC LIMITATIONS OR ADDITIONAL INSTRUCTIONS].

6. STATEMENT OF HEALTH-CARE INSTRUCTIONS

[// GUIDANCE: The following default instructions reflect common preferences. Customize as needed.]

6.1 Life-Sustaining Treatment.
If I am determined to be in a terminal condition or permanently unconscious state and Life-Sustaining Treatment would only prolong the dying process:
☐ I direct that such treatment be withheld or withdrawn.
☐ I direct that such treatment be provided.

6.2 Artificial Nutrition & Hydration.
☐ I do NOT want artificial nutrition or hydration if doing so only prolongs the dying process.
☐ I DO want artificial nutrition or hydration regardless of condition.

6.3 Pain Management & Palliative Care.
I direct that adequate medication be provided to relieve pain, even if such medication may hasten death, except [SPECIFY LIMITATIONS OR “none”].

6.4 End-of-Life Location Preference.
☐ Home  ☐ Hospice Facility  ☐ Hospital  ☐ No Preference

6.5 Mental-Health Treatment Instructions.
[INSERT SPECIFIC CONSENT OR REFUSAL OF MEDICATION, ECT, OR SECLUSION].

6.6 Anatomical Gifts & Organ Donation.
Upon my death:
☐ Donate any organs or tissues needed for transplantation, therapy, research, or education.
☐ Donate only the following: [LIST].
☐ Do not make organ or tissue donations.

7. HIPAA AUTHORIZATION

The Agent (and any Alternate Agent then serving) is designated as my “personal representative” for purposes of the Health Insurance Portability and Accountability Act of 1996 and may obtain, use, or disclose my protected health information to the full extent permitted by law.

8. NOMINATION OF GUARDIAN OR CONSERVATOR

If a court of competent jurisdiction determines that a guardian and/or conservator should be appointed for me, I nominate my Agent (or next available Alternate Agent) to serve. If such Agent is unwilling or unable, I nominate:
• [NAME / CONTACT INFO]

9. RELIANCE, IMMUNITIES & GOOD-FAITH LIABILITY CAP

9.1 Good-Faith Standard. Any health-care provider, institution, or individual that acts in good-faith reliance on this Directive, or on any decision of my Agent made pursuant hereto, shall not incur civil or criminal liability or be subject to professional disciplinary action for such reliance, to the fullest extent permitted by Maine law.

9.2 Indemnification. I agree that my estate shall indemnify and hold harmless any such provider or institution for costs or damages incurred as a direct result of good-faith compliance with this Directive.

[// GUIDANCE: This clause aligns with the “good faith” liability cap specified in the request metadata.]

10. REVOCATION & AMENDMENT

10.1 Revocation by Principal. I retain the right to revoke or amend this Directive at any time by:
a. A signed written revocation;
b. Physically destroying or defacing this document or directing another to do so in my presence;
c. An oral or any other expression of intent to revoke communicated to my primary physician or other health-care provider; or
d. Executing a subsequent advance directive.

10.2 Effect of Divorce or Legal Separation. If the Agent is my spouse, his or her authority is automatically suspended upon the initiation of divorce or legal separation proceedings unless expressly reaffirmed in writing thereafter.

11. COPIES; ELECTRONIC & PHOTOGRAPHIC RECORDS

A photocopy, facsimile, or electronically transmitted copy of this Directive shall have the same force and effect as an original.

12. GENERAL PROVISIONS

12.1 Governing Law. This Directive shall be governed by and construed in accordance with the laws of the State of Maine.
12.2 Severability. If any provision herein is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.
12.3 Amendment. Any amendment must be executed with the same formalities as this Directive.
12.4 Integration. This document constitutes the Principal’s complete directive concerning the matters addressed herein.

13. EXECUTION & ACKNOWLEDGMENT

I, the undersigned Principal, declare that I am at least 18 years of age and of sound mind, and that I am executing this Advance Directive voluntarily and after careful consideration.

Principal’s Signature: ____ Date: ____
Printed Name: [LEGAL NAME OF PRINCIPAL]

14. WITNESS ATTESTATION

We, the undersigned witnesses, affirm that:

1. The Principal voluntarily signed or directed another to sign this Advance Directive in our presence.
2. Each of us is at least 18 years of age.
3. Neither of us is the Agent, Alternate Agent, the Principal’s health-care provider, nor an employee of the health-care facility in which the Principal is a patient.
4. At least one of us is not related to the Principal by blood, marriage, or adoption and is not entitled to any portion of the Principal’s estate.

[// GUIDANCE: Maine requires two qualified witnesses. Notarization is optional but recommended.]

15. OPTIONAL NOTARY ACKNOWLEDGMENT

State of Maine
County of [__]

On this _ day of _, 20__, before me, the undersigned Notary Public, personally appeared [PRINCIPAL’S NAME], known to me or satisfactorily proven to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public, State of Maine
My Commission Expires: _______

END OF DOCUMENT

[// GUIDANCE:
1. Provide copies to the designated Agent(s), primary physician, and any facility likely to provide care.
2. Upload to the Maine advance directive registry if available and desired.
3. Review periodically—best practice is at least every five years or after any major life event.
]