ADVANCE HEALTH CARE DIRECTIVE
For Mental Health Care
Under the Uniform Health Care Decisions Act
18-A M.R.S.A. § 5-801 et seq.
I, ________________ currently of__________________________, ______________________,
name street address city
Maine, whose birth date is ________________, execute this Advance Health Care Directive
Attorney so that I might obtain mental health care and treatment.
PART I. POWER OF ATTORNEY FOR HEALTH CARE (Complete this part only if you are appointing an agent to make decisions for you.)
(1) DESIGNATION OF AGENT: I, designate the following individual as my agent to make mental health-care decisions for me:
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
(2) DESIGNATION OF ALTERNATIVE AGENT: (OPTIONAL) If I revoke this agent’s authority or if my agent is not willing, able or reasonably available to make mental health care decisions for me, I designate as my first alternate agent:
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
(address)
(city) (state) (zip code)
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___2___
(3) AGENT AND ALTERNATIVE AGENT UNAVAILABLE: If I revoke the authority of my agent and first alternate agent, if I have named one, or if neither my agent or alternate, if I have named one, is willing, able or reasonably available to make health-care decisions for me, the instructions in this health care directive are nevertheless to be followed without need for the express authorization of an agent. YES____ NO_____
(4) AGENT’S AUTHORITY: My agent is authorized to make all health-care decisions, consistent with the instructions and limitations as set out in this document, that in my agent’s judgment relate to psychiatric, psychological and emotional care and treatment, including the right to consent, withhold consent or withdraw consent to any test, procedure, program of medications or any form of mental health care and treatment and to select or discharge any mental health care providers or institutions.
(5) AGENT’S OBLIGATION: My agent shall make health-care decisions for me in accordance with this power of attorney for health care, any instructions I give in Part 2 of this form and my other wishes to the extent known to my agent. To the extent my wishes are unknown, my agent shall make health-care decisions for me in accordance with what the agent determines to be in my best interest. In determining my best interest, my agent shall consider my personal values to the extent known to my agent.
PART II: WHEN ADVANCE DIRECTIVE BECOMES EFFECTIVE (This part needs to be completed whether you are appointing an agent, giving instructions or doing both)
(6) WHEN ADVANCE DIRECTIVE (INCLUDING AGENT’S AUTHORITY, IF ONE APPOINTED) BECOMES EFFECTIVE: This advance directive becomes effective when: (Indicate the applicable options)
____ immediately (this option is available only if you have appointed an agent)
____ my primary physician, or, if I should be in an emergency room or in a treatment setting, the attending physician determines that I am unable to make my own health-care decisions.
_____ my primary physician, or, if I should be in an emergency room or in a treatment setting, the attending physician determines that I meet involuntary hospitalization standards.
_____ my primary physician, or, if I should be in an emergency room or in a treatment setting, the attending physician determines that if I do not receive psychiatric hospitalization or the
treatment as set out in this instrument my condition will quickly deteriorate such that I would soon meet the standard for involuntary hospitalization.
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___3___
______ other. Describe______________________________________________
________________________________________________________________________
________________________________________________________________________
The above options require a second physician’s opinion. Yes._____ No _____
I waive the 2nd opinion requirement if another physician is not available. Yes _____ No ______
(If I require a second opinion and do not waive the requirement should no second physician be available, I understand that my advance directive may not become effective.)
(7) NOMINATION OF GUARDIAN: (OPTIONAL) If a guardian of my person needs to be appointed for me by a court, I nominate the following individual to be appointed as my guardian.
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
PART 3: INSTRUCTIONS FOR HEALTH CARE (Optional if you have appointed an agent. ) (If giving instructions, you can choose those specific areas you wish to address and can add additional areas.)
I request that I be provided the following treatment:
I. Alternatives to hospitalization
In the event my condition becomes serious enough that I am found to need 24 hour care, I prefer to avoid hospitalization as possible, and request that the following services be explored first.
_____ Crisis respite services. I prefer to receive the services at the following agencies: ______ names of agencies
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___4___
_____ Crisis respite services. I prefer to receive the services at the following agencies: ______ names of agencies ______________________________________________________________________________
if you have preferences
______________________________________________________________________________
____ In-home services. I prefer to receive the following services: _______________________ names of agencies
_____________________________________________________________________________________________________________________
if you have preferences and description of services.
_______ Other services (describe) ___________________________________________________
______________________________________________________________________________
My reasons for wanting these services as alternatives to hospitalization are as follows:
(optional, but recommended)______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
II. Psychiatric Hospitalization
In the event that psychiatric hospitalization is the only suitable alternative, I direct that it be sought at the following hospitals in the following order of priority:
_____________________________________________
name of hospital
_____________________________________________
name of hospital
_____________________________________________
name of hospital
_____________________________________________
name of hospital
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___5___
This directive may operate as my informed consent to admission as a voluntary patient to the above listed hospitals.
This consent shall operate even if I pose any verbal objections at the time. Yes_____ No _____
If none of the above hospitals have available beds, this directive may operate as my informed consent to admission to any other hospital as follows: (Select applicable option)
_______ To any other hospital, provided I do not object at the time.
_______ To any other hospital, even if I am objecting at the time, except for the following listed hospitals.
_______________________________________________
name of hospital to which my consent is not given
_______________________________________________________________________
name of hospital to which my consent is not given
_______________________________________________
name of hospital to which my consent is not given
My reasons for wanting these psychiatric hospitalization options are as follows:
(optional, but recommended)______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
If I need to be transported to a psychiatric hospital as an involuntary patient, I request that I be transported by the following means:
_______ Ambulance
_______ Sheriff or police vehicle. (I understand that by requesting this service I am waiving any claims or rights I may have under law to be transported in a medically equipped vehicle in the company of emergency medical technicians or other medically trained personnel.)
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___6___
Other notes regarding transportation and my reasons for requesting transportation by this
means are as follows: ____________________________________________________________
______________________________________________________________________________
III. Medications
I consent, and my agent if appointed is authorized to consent to the administration of medications as follows. (select options)
Medication Dosage Limits, if any Only Orally
If checked
____________________________ ______________________________ ____________
____________________________ ______________________________ ____________
____________________________ ______________________________ ____________
____________________________ ______________________________ ____________
____ All medications as prescribed by my primary physician, except as may be limited below.
_____ All medications as authorized by my agent, if appointed, except as may be limited below.
______ I do not authorize and my agent, if appointed, may not consent to the following medications.
Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
My reasons for not consenting to the above medications is as follows: (optional but
recommended) _________________________________________________________________
______________________________________________________________________________
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___7___
______ If any action can be taken to eliminate my above stated concerns regarding the excluded medications, my agent, if appointed, is authorized to consent to their administration provided such additional action is taken to accommodate my stated concerns.
________ Other instructions with regard to medications: _______________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
IV. Emergency Interventions while in a hospital
I understand that while I am in a psychiatric facility certain interventions may be authorized in an emergency should my behavior be imminently dangerous to myself or others.
I believe such an emergency can be avoided if I am treated in the following way: _____
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
If an emergency nevertheless arises, I prefer emergency interventions be implemented as follows: (State preferences with regard to the use of seclusion, restraint, offer of oral medications, medications by injection.)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
V. Other treatment while in a hospital
I have responded favorably to the following treatment in a hospital setting, and request that these treatment options be offered.
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___8___
Describe treatment options (family therapy, for example) _______________________________
_____________________________________________________________________________
_____________________________________________________________________________
__________________________________________________________________
VI. Electroconvulsive Therapy (ECT)
____ I do not consent and my agent is not authorized to consent to the administration of ECT.
_____ I consent to the administration of ECT as prescribed by my primary physician, except as
may be limited below.
____ I consent to the administration of ECT as authorized by my agent, except as may be
limited below.
_____ Limitations upon consent to the administration of ECT:
_______ My consent is limited to _______ number of treatments.
_______ Consent may not be sought from my agent, if one is appointed, until s/he has had _____ days to consider the risks and benefits of the treatment.
_______ My consent is otherwise limited as follows: _____________________________
______________________________________________________________________________
______________________________________________________________________________
My reasons for consenting or refusing ECT as set out above, is as follows: (optional, but
recommended)______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___9___
VII. Notices
If I am admitted to a facility, I request that the following individuals be notified immediately.
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
VIII. Child Care Arrangements If I am to be admitted to residential care or to a hospital, or I am otherwise unable to care for my children, and I have not made prior child care arrangements, I authorize my agent to make those arrangements. If my agent or alternative is not
available, I request that the following individual be contacted to care for my children temporarily:
__________________________________________ ______________________________
(name of individual) (home phone) (work phone)
________________________________________________________
(address)
________________________________________________________
(city) (state) (zip code)
IX. Other Instructions
______________________________________________________________________________
______________________________________________________________________________
HEALTH CARE DIRECTIVE AND POWER OF ATTORNEY of _______________________ Page ___10___
PART 4: PRIMARY PHYSICIAN
I designate the following as my primary physician, for the purposes of this directive:
______________________________________________ _______________________
(name of physician) (phone number)
______________________________________________
(address)
______________________________________________
(address)
___________________________________________________________________
(city) (state) (zip code)
A COPY OF THIS FORM HAS THE SAME EFFECT AS THE ORIGINAL.
________________________________________ Dated: ______________________________
signature
_________________________________________ ____________________________________
witness signature witness signature
_________________________________________ ____________________________________
witness Address witness address
______________________________________________________ ________________________________________________
city state zip code city state zip code
Dated:___________________________________ Dated: ______________________________ | 
