Maine Living Will Template
This Living Will is made in accordance with the laws of the State of Maine. It outlines my wishes regarding medical treatment in the event that I become unable to communicate my preferences.
Personal Information:
- Name: __________________________
- Date of Birth: ___________________
- Address: ________________________
- City, State, Zip: ________________
Declaration:
I, the undersigned, declare that if I am diagnosed with a terminal condition or am in a persistent vegetative state, I do not wish to receive the following treatments:
- Cardiopulmonary resuscitation (CPR)
- Mechanical ventilation
- Artificial nutrition and hydration
- Other life-sustaining treatments: ________________
Additional Wishes:
If there are specific wishes regarding pain relief or comfort care, please outline them here:
______________________________________________________
Appointment of Healthcare Proxy:
I designate the following individual as my healthcare proxy to make medical decisions on my behalf if I am unable to do so:
- Name: __________________________
- Relationship: ___________________
- Phone Number: _________________
Signatures:
By signing below, I affirm that I am of sound mind and that this document reflects my wishes regarding medical treatment.
Signature: ________________________
Date: _____________________________
Witnesses:
This Living Will must be signed in the presence of two witnesses who are not related to me and do not stand to inherit from me.
- Witness 1 Name: ______________________
- Witness 1 Signature: __________________
- Date: ________________________________
- Witness 2 Name: ______________________
- Witness 2 Signature: __________________
- Date: ________________________________
This Living Will is effective immediately upon signing.