HEALTH CARE DIRECTIVE
of ____________________

I, ____________________ (the "Maker"), of ______________________________________________________________, phone: __________, being of sound mind and at least 16 years of age, make this Health Care Directive fully understanding the consequences of my action in doing so. I intend this Health Care Directive to be read by my health care providers, family and friends as a true reflection of my wishes and instructions should I lack Capacity and be unable to communicate such wishes and instructions.

1. Definitions
   
1. As used in this document:
   
   1. "Act" means the Manitoba Health Care Directives Act.
      
   2. "Capacity" means that the person is able to understand the information that is relevant to making a health care decision and is able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.
      
2. Revoke Previous Health Care Directive
   
2. I revoke any previous Health Care Directive made by me.
   
3. Designation of Proxy
   
3. I do not wish to designate a Proxy, but provide the following information and instructions to be followed by a service provider who intends to provide personal services for me.
   
4. Notwithstanding the previous clause, I give no one (including my Proxy) any authority to disregard or override my instructions provided in this Personal Directive. Family members, relatives, friends may disagree with me, but any such disagreement does not diminish the strength or substance of my instructions.
   
5. Treatment Directions and End-Of-Life Decisions
   
5. I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
   
   1. If I have an incurable and irreversible terminal condition that will result in my death within a relatively short time, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   2. If I am diagnosed as persistently unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   3. If I am diagnosed as being severely and permanently mentally impaired, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
6. Revocation
   
6. The authority granted in this Health Care Directive may be revoked as and where permitted by law.
   
7. I understand that, as long as I have Capacity, I may revoke this Health Care Directive at any time.
   
8. Statement of Values and Beliefs
   
8. ________________________________________________________________________________________________________________________.
   
9. General
   
9. A copy of this Health Care Directive has the same effect as the original.
   
10. If any part or parts of this Health Care Directive is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of that part or parts will not in any way affect the remaining parts and this document will be construed as though the invalid or illegal part or parts had never been included in this Health Care Directive. But if the intent of this Health Care Directive would be substantially changed by such construction, then it shall not be so construed.
    
11. This Health Care Directive is intended to be governed by the laws of the Province of Manitoba.
    

Signature

Signed by me in the Province of Manitoba, this ________ day of ________________, ________.

Record of Copies
Record of people and institutions to whom I have given a copy of this Health Care Directive:

General comments regarding your Health Care Directive

1. Read the entire document before you sign in the space provided. Make sure it says what you want it to say.
   
2. Do not leave any blank lines above your signature to be filled in after signing. Make sure there are no blank lines before you sign.
   
3. Each page should be numbered. (e.g. 1 of 3, 2 of 3, etc.)
   
4. You and your witnesses should initial all the pages.
   

Signing requirements for your Manitoba Health Care Directive

- A Health Care Directive must be signed by the Maker.
               - Where the Maker is physically unable to sign, another person may sign at the direction and in the presence of the Maker. Where there is a substitute signer, the Maker must acknowledge the signature in the presence of a witness. The witness must not be a proxy appointed in the directive or a proxy's spouse, and the witness must sign the directive as witness in the presence of the Maker.

Limitations to the authority of your Proxy

Unless specified otherwise in the Health Care Directive, a proxy cannot consent to:
               - medical treatment for the primary purpose of research;
               - sterilization that is not medically necessary for the protection of the maker's health; or
               - the removal of tissue from the maker's body, while living, for transplantation to another person, or for the purpose of medical education or medical research.