Maine Living Will Template
This Living Will is created in accordance with the laws of the State of Maine. It designates your preferences and instructions concerning medical treatment in the event that you become unable to communicate your wishes.
Personal Information
- Full Name: ______________________________
- Address: ______________________________
- City, State, Zip Code: ______________________________
- Date of Birth: ______________________________
Directive Statement
If at any time I become unable to make healthcare decisions for myself, I want my medical treatment to be directed by the preferences I have outlined below:
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If I am diagnosed with a terminal condition and unable to communicate:
- ☐ I wish to receive all available treatments to prolong my life.
- ☐ I do not wish to receive treatments that only prolong the process of dying.
-
If I am in a persistent vegetative state:
- ☐ I wish to receive all available treatments to prolong my life.
- ☐ I do not wish to receive treatments that only prolong the process of dying.
-
Other preferences:
______________________________________________________________________________
Appointment of Healthcare Agent
If I am unable to make my own healthcare decisions, I designate the following person as my healthcare agent:
- Full Name of Healthcare Agent: ______________________________
- Address: ______________________________
- Phone Number: ______________________________
Signatures
By signing this document, I affirm that I understand its contents and that it reflects my wishes regarding medical care.
- Signature: ______________________________
- Date: ______________________________
This Living Will should be witnessed by at least two adults, neither of whom may be related to me or entitled to any portion of my estate:
- Witness 1 Name: ______________________________
- Witness 1 Signature: ______________________________
- Date: ______________________________
- Witness 2 Name: ______________________________
- Witness 2 Signature: ______________________________
- Date: ______________________________