Personal Directive (Canada) Form

What is a Personal Directive?

A Personal Directive or Living Will allows you to designate someone who will make health care and personal care decisions for you when you are not able and also to provide instructions for future care while you are still capable of making decisions for yourself.

A Personal Directive provides an opportunity for you to discuss treatment options with your medical staff as well as to discuss and resolve difficult issues with your family and friends.

Your directive must be made while you are still capable of giving consent.

(Also called a Living Will, Advance Directive, Health Care Directive, or Power of Attorney for Personal Care)

Governing Law

The laws of which province will govern this agreement?

You must select a governing law.

A Health Care Directive is not available for Quebec.

A Health Care Directive is not available for Nunavut.

In the State of sel this document is known as a Power of Attorney for Personal Care.

In the State of sel this document is known as a Representation Agreement.

British Columbia

Special Note:

British Columbia has special requirements concerning Representation Agreements. In almost all circumstances you will need to review your Representation Agreement with a qualified lawyer and obtain a Consultation Certificate to ensure that all terms of your Representation Agreement are acceptable.

Yukon

Special Note:

The Yukon has special requirements concerning an Personal Directive. If you authorize your Proxy to give consent to certain therapies or procedures then you will need to review your Personal Directive with a qualified lawyer and obtain a Certificate of Legal Consultation.

Display the list of therapies and procedures that require a legal consultation.

(1) consent to physically restrain, move, or manage the Maker, or have the Maker physically restrained, moved, or managed, when necessary and despite the objections of the Maker;
(2) consent to specified kinds of health care, even though the Maker is refusing to give consent at the time the health care is provided;
(3) consent to waive the Maker's right to apply to the board for a decision respecting the Maker's incapability to give or refuse consent under this Act;
(4) abortion (unless recommended by your physician and at least one other medical practitioner);
(5) electroconvulsive therapy (unless recommended by your physician and one other medical practitioner);
(6) consent to the removal of tissue from the Maker for implantation in another human body or medical research;
(7) consent to experimental health care for the Maker involving a foreseeable risk that is not outweighed by the expected therapeutic benefit;
(8) consent to participation by the Maker in a health care or medical research program that has not been approved by a recognized ethics committee; or
(9) consent to any treatment, procedure or therapy that involves using punishment to cause a change in behaviour.

Your Information (the Maker)

Please select a governing law.

Remember: The Personal Directive must be made while the Maker still has the capacity to give consent.

Full Name:

(e.g. James Tiberius Smith)

Street Address:

(e.g. 47 Grosvenor Avenue)

Town/City:

(e.g. Saskatoon)

Province:

Postal Code:

(e.g. V1V 1V1)

Phone:

(e.g. (999) 999-9999)

Gender

I wish to revoke any previous directive made by me.

Designate Agent and Alternates

In sel you do not have to designate an Agent. In some cases you may not have friends or family that are willing and able to act as Agent. However, if possible you should try to designate someone to act as your Agent and discuss your wishes with that person so that they can be prepared to make decisions concerning your personal care especially concerning issues that you had not specifically anticipated in your Personal Directive.

I wish to designate one or more Agents.

Number of Agents I wish to designate:

In Nova Scotia, if you appoint two or more delegates, the delegates must act successively (meaning that the first named delegate will have authority to make decisions unless that delegate is unable or unwilling to act then authority will pass to the next available delegate) OR you must assign to each of the delegates authority over different matters.

Name and Address

Name and Address for Agent #1:

Name:

Address:

(e.g. 10110-101 street)

Town/City:

(e.g. Saskatoon)

Province:

Phone:

(e.g. (999) 999-9999)

Email:

(e.g. simonb@webware.com)

Date of Birth:

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Duties and Authority of Agent

I give my Agent full authority to make all personal decisions on my behalf.

"Personal decisions" typically includes all decisions relating to healthcare, accommodation, participation in social activities, the people with whom I may live and associate, where I may work, educational activities, and authority over legal matters)

Areas of Authority you wish to designate for your primary Agent

Describe the limited areas of authority that you wish to give to your Agent:

Remember: In Nova Scotia, you must assign different areas of authority to each of the delegates. Where delegates have common areas of authority they must act successively meaning that the first named delegate will have authority to act unless that delegate is unable or unwilling to act then authority will pass to the next delegate named.

Agent #1:

(e.g. healthcare, accommodation, participation in social activities, the people with whom I may live and associate, where I may work, educational activities, authority over legal matters, etc.)

Decision Making

Where two or more Agent have authority they will make decisions:

Jointly - means that the Agent will work together and make decisions through unanimous or majority agreement.
Successively - means that the first named Agent will have authority to make decisions but where that Agent is unable or unwilling to act then authority will pass to the next available Agent in the order you indicate above.

Where two or more Agent are acting jointly they will make decisions by:

Specific Instructions

I wish to provide specific instructions for my Agent:

Specific Instructions for my Agent:

I wish to provide specific instructions for my service provider:

Where you have not selected an Agent to make decisions for you, you may wish to leave specific instructions for your service provider.

Specific Instructions for my service provider:

Determination of Incapacity

I wish to designate the individuals who will determine my incapacity.

You may designate one or more persons who, in consultation with a physician or psychologist, will make a written declaration that you lack capacity.

If you decide not to designate anyone now then a determination of incapacity may be made later by two service providers responsible for your care where at least one service provider is a physician or a psychologist.

Number of individuals I wish to designate:

Name and Address

Name:

Address:

Confidential Information

I wish to provide instructions with respect to access to confidential information about the Maker.

Instructions with respect to access to confidential information:

Designate Agent for temporary care of minor children.

I wish to designate an Agent for temporary care and education of minor children.

Number of Agents for care of minor children:

Agent for Minor Children

Agent Name:

Agent Address:

Statement of Values and Beliefs

An Advance Statement is a description of your views and beliefs that you wish to be taken into account if health care decisions are being made for you. While such a statement is not binding on medical professionals, it could provide them with the kind of information they need to make decisions for you when you are no longer able to do so for yourself. This feature is optional.

I wish to include a statement of my basic values and beliefs.

Type your Advance Statement of values and beliefs here:

(e.g. My fundamental belief is that a person should be allowed to die with grace and dignity and that a life should not be prolonged with aggressive medical treatment where the resulting quality of life is poor and where there is no reasonable expectation of recovery.)

View more examples.

Example #1:
I prefer to be treated at home where I may be closer to my family and friends.

Example #2:
In the event that I no longer have capacity to refuse or consent to health care on my own behalf it is my intent that this Personal Directive be respected by my physicians, my family and friends, as well as any other caregivers.

Example #3:
I am bound by my religious beliefs to refuse the following treatments or types of treatments:
- Blood transfusion
- Organ transplant
- Other

Treatment Directions and End-of-Life Decisions

Below, you can select what kinds of treatment you would or would not want to receive if you should be diagnosed with a terminal condition. If you would prefer to specify something different about a particular kind of treatment, select "other" and type your instruction in the space provided.

Terminal Condition

If my condition is determined to be terminal and with no hope of recovery, I would like the following done:

Life Support:

Enter your own instructions for Life Support:

Tube Feeding:

Enter your own instructions for Tube Feeding:

CPR:

Enter your own instructions for CPR:

Intervening Illness:

Enter your own instructions concerning Intervening Illnesses:

Persistent Unconsciousness

If I am persistently unconscious with no hope of recovery, I would like the following done:

Life Support:

Enter your own instructions for Life Support:

Tube Feeding:

Enter your own instructions for Tube Feeding:

CPR:

Enter your own instructions for CPR:

Intervening Illness:

Enter your own instructions concerning Intervening Illnesses:

Severe and Permanent Mental Impairment

If I am severely and permanently mentally impaired, I would like the following done:

Life Support:

Enter your own instructions for Life Support:

Tube Feeding:

Enter your own instructions for Tube Feeding:

CPR:

Enter your own instructions for CPR:

Intervening Illness:

Enter your own instructions concerning Intervening Illnesses:

Comfort and Dignity

Include the following statement in my Living Will regarding behavior controlling drugs:

"If I am suffering from one of the above-mentioned conditions and if my behaviour becomes violent or is otherwise degrading, I want my symptoms to be controlled with appropriate drugs, even if that would worsen my physical condition or shorten my life."

Include the following statement in my Living Will regarding pain controlling drugs:

"If I am suffering from one of the above mentioned conditions and I appear to be in pain, I want my symptoms to be controlled with appropriate drugs, even if that would worsen my physical condition or shorten my life."

Other Treatments

I have strong feelings about certain kinds of treatment I wish to express in my Living Will.

Indicate your consent or refusal to each of the following treatments:

Antibiotics:

ConsentRefuseDo Not Specify

Blood Transfusion:

ConsentRefuseDo Not Specify

Chemotherapy:

ConsentRefuseDo Not Specify

Defibrillation (heart stimulation):

ConsentRefuseDo Not Specify

Intravenous (IV) Therapy:

ConsentRefuseDo Not Specify

Intubation (for breathing):

ConsentRefuseDo Not Specify

Kydney Dialysis:

ConsentRefuseDo Not Specify

Radiation:

ConsentRefuseDo Not Specify

Surgery:

ConsentRefuseDo Not Specify

I have strong feelings about other treatments that I wish to express in my Personal Directive.

Give additional instructions about any potential treatment that concerns you:

(e.g. My religious beliefs strictly prohibit any medical treatment that involves the transfusion of whole blood or the transfusion of constituent blood products including red cells, white cells, platelets or plasma even in the case of a medical emergency.)

Organ Donation

I want to give directions about organ donation.

Organ donation:

Type your wishes, instructions or beliefs about organ donation here:

Revocation

This Personal Directive may be revoked:

Enter a specific date when this Personal Directive will be revoked:

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Enter the event or conditions under which this Personal Directive will be revoked:

(e.g. As soon as I regain capacity after heart surgery.)

Agent Acknowledgment

I want my Agent to sign and acknowledge my Personal Directive.

Notification of Incapacity

I wish to designate the individuals who need to be notified in the event of my incapacity.

Other than yourself and your Agent, who else do you wish to be notified if you are declared incapable of making decisions for yourself.

Number of individuals that need to be notified:

Name and Address

Name:

(e.g. James Tiberius Smith)

Address:

(e.g. 10110-101 street)

Town/City:

(e.g. Saskatoon)

Province:

Postal Code:

(e.g. V1V 1V1)

Additional Instructions

You may want to provide instructions about other issues that concern you. Some examples are:
- Who you want to be with you during your final moments.
- Who you would prefer not to be present during your illness.
- Who will care for your pets during your illness.

I want to include additional instructions.

Type your additional wishes, instructions or beliefs here:

In British Columbia a substitute decision maker cannot consent to the following:

(1) abortion (unless recommended by your physician and at least one other medical practitioner);
(2) electroconvulsive therapy (unless recommended by your physician and one other medical practitioner);
(3) psychosurgery;
(4) removal of tissue from a living human body for implantation in another human body;
(5) removal of tissue from a living human body for medical education or research;
(6) experimental health care involving a foreseeable risk that is not outweighed by the expected benefits;
(7) participation in medical research that has not been approved as described by regulation; and
(8) any treatment, procedure or therapy that involves using punishment to cause a change in behaviour.

Signing Details

Execution date:

Specific signing date:

Open the calendar popup.

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I am physically unable to sign

I am physically incapable of signing this Personal Directive for myself.

Where you are physically incapable of signing this Personal Directive, another person may sign for you.

Enter the following information regarding the person who will sign on your behalf:

Full Name:

(e.g. James Tiberius Smith)

Street Address:

(e.g. 47 Grosvenor Avenue)

Town/City:

Province

Postal Code:

Phone:

(e.g. (999) 999-9999)

Who can be a witness?

Please select a governing law.

British Columbia

Remember:

If your Representation Agreement includes any of the following terms or authorizations then you will need to consult with a qualified attorney and obtain a Consultation Certificate in order to ensure your terms are valid:

- authority to physically restrain move or manage the person;
- authority to consent to provide health care even thought the person refuses consent at the time;
- authority to refuse consent to healthcare including life support;
- authority to accept admission to any kind of care facility;
- authority to make arrangements for the care, education and support of a minor child or adult dependent person.

If any of the above terms are included in your Representation Agreement then you must consult with a qualified attorney and obtain a Consultation Certificate.

Yukon

Remember:

If your Personal Directive includes any of the following terms or authorizations then you will need to consult with a qualified attorney and obtain a Consultation Certificate in order to ensure your terms are valid:

(1) consent to physically restrain, move, or manage the Maker, or have the Maker physically restrained, moved, or managed, when necessary and despite the objections of the Maker;
(2) consent to specified kinds of health care, even though the Maker is refusing to give consent at the time the health care is provided;
(3) consent to waive the Maker's right to apply to the board for a decision respecting the Maker's incapability to give or refuse consent under this Act;
(4) abortion (unless recommended by your physician and at least one other medical practitioner);
(5) electroconvulsive therapy (unless recommended by your physician and one other medical practitioner);
(6) consent to the removal of tissue from the Maker for implantation in another human body or medical research;
(7) consent to experimental health care for the Maker involving a foreseeable risk that is not outweighed by the expected therapeutic benefit;
(8) consent to participation by the Maker in a health care or medical research program that has not been approved by a recognized ethics committee; or
(9) consent to any treatment, procedure or therapy that involves using punishment to cause a change in behaviour.

If any of the above terms are included in your Personal Directive then you must consult with a qualified attorney and obtain a Consultation Certificate.

Personal Directive - Canada

The Simplest way to ensure that your health care wishes are carried out.

What is a Personal Directive?

Governing Law

British Columbia

Yukon

Your Information (the Maker)

Designate Agent and Alternates

Name and Address

Duties and Authority of Agent

Areas of Authority you wish to designate for your primary Agent

Decision Making

Specific Instructions

Determination of Incapacity

Name and Address

Confidential Information

Designate Agent for temporary care of minor children.

Agent for Minor Children

Statement of Values and Beliefs

Treatment Directions and End-of-Life Decisions

Terminal Condition

Persistent Unconsciousness

Severe and Permanent Mental Impairment

Comfort and Dignity

Other Treatments

Organ Donation

Revocation

Agent Acknowledgment

Notification of Incapacity

Name and Address

Additional Instructions

Signing Details

Who can be a witness?

British Columbia

Yukon

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