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Maine Do Not Resuscitate Form


Maine Do Not Resuscitate Form
Maine Do Not Resuscitate Form
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Revised February 2008
Maine Health Care
Advance Directive Form
You may use this form now to tell your physician and others what medical care you want to receive if you
become too sick in the future to tell them what you want. You may choose to fill out the whole form or any
part of the form and then sign and date the form in Part 6. These are the parts:
Part 1
Fill this out if you want to choose someone to make all your health care decisions for you,
either right away or if you become too sick to tell others what you want. This person is
called your agent.
Part 2
Fill this out if: (1) you did not name an agent in Part 1 and now want to choose whether
you want certain treatments or, (2) you did name an agent in Part 1 and want to tell your
agent your wishes about certain treatments, knowing that your agent must follow your
directions.
Part 3
Fill this out if you want to give the name of your primary physician, physician assistant or
nurse practitioner.
Part 4
Fill this out if you want to make decisions about donating your organs, body or tissues
after your death.
Part 5
Fill this out if you want: (1) to choose someone to make all funeral and burial decisions
after your death, or (2) to tell your family any wishes you have about funeral and burial
decisions.
Part 6
You must sign and date your Advance Directive form on this page. Have two witnesses
sign the form at the same time you sign it. Tell others about your decisions and give
copies to your physician, other health care providers, family and hospital.
Part 7
If you do not wish to be revived by ambulance crews should your heart or breathing stop,
then you and your physician (or nurse practitioner or physician assistant) need to sign this
Do Not Resuscitate (DNR) form.
Maine Do Not Resuscitate Form
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