PERSONAL DIRECTIVE
of ____________________

I, ____________________ (the "Maker"), of ______________________________________________________________, phone: __________, being of sound mind and at least 18 years of age, make this Personal Directive fully understanding the consequences of my action in doing so. I intend this Personal 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 Nova Scotia Personal Directives Act.
      
   2. "Capacity" means the ability to understand information that is relevant to the making of a personal care decision and the ability to appreciate the reasonably foreseeable consequences of a decision or lack of a decision.
      
2. Revoke Previous Personal Directive
   
2. I revoke any previous Personal Directive made by me.
   
3. Designation of Delegate
   
3. I designate the following person to act as my delegate (my "Delegate"):
   
   ________________________________
   ______________________________________________________________
   Phone: __________
   __________
   
4. Duties and Authority of Delegate
   
4. Where I do not have Capacity to make decisions for myself, I give my Delegate full authority to make personal care decisions, major health care decisions, and minor health care decisions on my behalf.
   
5. Notwithstanding the previous clause, I give no one (including my Delegate) 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.
   
6. In Force
   
6. The authority granted to my Delegate under this Personal Directive will be in effect only if and as long as I have been found to lack Capacity.
   
7. Treatment Directions and End-Of-Life Decisions
   
7. 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.
         
8. Revocation
   
8. The authority granted in this Personal Directive may be revoked as and where permitted by law.
   
9. I understand that, as long as I have Capacity, I may revoke this Personal Directive at any time.
   
10. Delegation of Authority
    
10. A Delegate cannot delegate his or her authority as delegate.
    
11. Statement of Values and Beliefs
    
11. ________________________________________________________________________________________________________________________.
    
12. Liability of Delegate
    
12. A Delegate will not be liable for any mistake or error in judgment or for any act or omission believed to be made in good faith and believed to be within the scope of authority conferred or implied by this Personal Directive and by the Act.
    
13. Without limiting the liability of the Delegate, the Delegate will be liable for any and all acts and omissions involving intentional wrongdoing.
    
14. General
    
14. A copy of this Personal Directive has the same effect as the original.
    
15. If any part or parts of this Personal 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 Personal Directive. But if the intent of this Personal Directive would be substantially changed by such construction, then it shall not be so construed.
    
16. This Personal Directive is intended to be governed by the laws of the Province of Nova Scotia.
    

Signature

Signed by me under hand and seal in the presence of my witness in the Province of Nova Scotia, this ________ day of ________________, ________.

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

General comments regarding your Personal 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 witness should initial all the pages.
   

Signing requirements for your Nova Scotia Personal Directive

- The Personal Directive must be dated and signed by the Maker in the presence of a witness who must also sign.
               - Where the Maker is physically unable to sign, the Personal Directive must be signed by a person (substitute signer) on behalf of the maker and at the maker's direction and in the maker's presence, and in the presence of a witness who must also sign.
               - A substitute signer cannot be a delegate or the spouse of a delegate.
               - A witness cannot be a delegate, a spouse of a delegate, a person who signs on behalf of the maker or the spouse of a person who signs on behalf of the maker.

Limitations to the authority of your Delegate

- A delegate has no authority to make decisions relating to health care that are prohibited by regulations unless the Personal Directive contains specific instructions that allow those decisions.