Free Health Care Directive

A Health Care Directive states your preferred medical treatments in case you’re unable to.
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Health Care Directive

Statement of Values and Beliefs


Statement of Values and Beliefs

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.


Frequently Asked Questions
What is an Advance Statement?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.

Use correct spelling and punctuation. Your Advance Statement will appear in your document exactly as you have typed it.
Show 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


Your Health Care Directive

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Health Care Directive Page of
Page of

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
  2. As used in this document:
    1. "Act" means the Personal Directive.
    2. "Capacity" means the individual is able to understand the information pertaining to the personal decision and also is able to understand the reasonably foreseeable consequences of the decision.
  3. Designation of Agent
  4. I do not wish to designate an Agent, but provide the following information and instructions to be followed by a service provider who intends to provide personal services for me.
  5. Notwithstanding the previous clause, I give no one (including my Agent) 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. Revocation
  7. The authority granted in this Personal Directive may be revoked as and where permitted by law.
  8. I understand that, as long as I have Capacity, I may revoke this Personal Directive at any time.
  9. General
  10. A copy of this Personal Directive has the same effect as the original.
  11. 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.
  12. This Personal Directive is intended to be governed by the laws of the Province of .


Signature

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

______________________________________
(Signature of the Maker)

______________________________________
(Signature of the witness in the presence of Maker)


______________________________________
(Printed name of the witness)


______________________________________


______________________________________


______________________________________


______________________________________
(Address of witness)


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

1.

________________________________________

Date: ____________________

2.

________________________________________

Date: ____________________

3.

________________________________________

Date: ____________________

4.

________________________________________

Date: ____________________

5.

________________________________________

Date: ____________________


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 Personal Directive

Please select a province (jurisdiction).


Limitations to the authority of your Agent

Please select a province (jurisdiction).

Living Will Information

A Living Will, also known as a Personal Directive or Advance Directive, is a document that you use to define your personal health care wishes in the event of an emergency.

It allows you to name your preferences in relation to resuscitation and comfort care, as well as designate a personal agent to enforce your choices. LawDepot's Living Will may be used in all provinces and territories excluding Quebec and Nunavut.

Do I need to name a personal agent in my Living Will?

A personal agent is the person who will enforce your health care preferences should you become incapable of doing so yourself. In some provinces, if you do not select an agent, your Living Will can be given to your health care provider to follow.

When you name an agent, you have the option to either give them full authority or limited authority over your health care decisions. Full authority means that your agent may enforce all of your decisions and also make undocumented decisions on your behalf, inform people of your incapacitation, and more.

What is a "statement of values and beliefs"?

A statement of values and beliefs is a non-binding personal statement given in a Living Will. It specifies your personal beliefs and morals that may be relevant to your health care, but it is not binding to doctors or health care providers.

The purpose of a statement of beliefs and values is to provide any extra information that may affect your treatment if you are hospitalized, such as your definition of quality of life or beliefs regarding specific treatments.

What is incapacitation in a Living Will?

When a person becomes incapacitated, it means that they are either mentally or physically unable to act for themselves in terms of managing their affairs. Incapacitation can be caused by illness, age, or an accident, and may be temporary or permanent depending on the situation.

In your Living Will, you may select individuals of your choice to determine whether or not you are incapacitated.

You may also choose who you wish to inform in the event of your incapacitation, for example, a spouse or your children.

What decisions can I make in a Living Will?

A Living Will allows you to make decisions for three different instances: terminal illness, persistent unconsciousness, and severe and permanent mental impairment. You will need to determine your preferences for:

  • Life support
  • Tube feeding
  • CPR
  • Intervening illness

You may also list whether or not you would like to be on organ donor, if you have any feelings about specific treatments, and how symptoms, such as pain, should be controlled.

A Living Will also allows you to designate a temporary guardian for your children in the event of an emergency.

Related Documents:

  • Last Will and Testament: a document used to allocate personal assets to beneficiaries upon death
  • End-of-Life Plan: a document used to put your end-of-life wishes into writing, including burial and memorial preferences and more
  • Power of Attorney: a document used to name a personal representative to oversee real estate, business, financial, and other matters in the event of incapacitation
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