Personal Directive - Template, Sample Form to Complete Pro · EN-CA-law
✓ Valid in Canada (English) · drafted to comply with local law
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PERSONAL DIRECTIVE
(Made pursuant to the Personal Directives Act, RSA 2000, c P-6, and the Personal Directives Regulation, Alta Reg 99/2008)
§ 1. IDENTIFICATION OF THE MAKER
1.1. I, ________, born on ________, currently residing at ________, in the City of ________, in the Province of Alberta, being a person who is 18 years of age or older and who understands the nature and effect of this document, make this Personal Directive of my own free will.
1.2. I make this Personal Directive in accordance with the Personal Directives Act, RSA 2000, c P-6 (the "Act"), and I intend that this document have full force and effect as a personal directive under the Act.
§ 2. REVOCATION
2.1. I revoke any previous personal directive made by me.
§ 3. APPOINTMENT OF AGENT
3.1. I designate ________, currently of ________, whose telephone number is ________, to be my agent.
3.2. I confirm that my agent is 18 years of age or older and has consented in writing to act as my agent, as required by the Act.
§ 4. ALTERNATE AGENT
4.1. If the person I have appointed in § 3.1 cannot or will not act as my agent by reason of refusal, resignation, death, mental incapacity, or removal by a court, I substitute ________, currently of ________, whose telephone number is ________, to act as my agent with the same authority as the person he or she replaces.
4.2. Where I have appointed more than one agent to act jointly, and one of them is unable or unwilling to continue to act, the remaining agent(s) shall continue to act unless this Personal Directive provides otherwise.
§ 5. AUTHORITY OF AGENT
5.2. My agent shall exercise authority in accordance with my known wishes and, where my wishes are not known, in my best interests, as required by section 14 of the Act.
5.3. I give no one, including my agent, authority to disregard or override the instructions I have provided in this Personal Directive. Any disagreement with my instructions does not diminish the strength or substance of those instructions.
5.4. Nothing in this Personal Directive authorizes my agent to consent to anything prohibited by law, and any direction given by me that is contrary to law is of no force or effect.
§ 6. COMPENSATION AND EXPENSES
6.1. I direct that my agent receive compensation in the amount of ________, or, if no amount is specified, such compensation as is permitted by applicable law.
6.2. My agent is entitled to reimbursement from my estate for reasonable expenses properly incurred in carrying out the agent's authority under this Personal Directive.
§ 7. DELEGATION OF AUTHORITY
7.1. An agent may not delegate his or her authority as agent, except as expressly permitted by the Act.
§ 8. LIABILITY OF AGENT
8.1. An agent who acts or makes a decision in good faith and in accordance with this Personal Directive and the Act is not liable for any loss, mistake or error in judgment, or for any act or omission, that the agent believed in good faith to be within the scope of the authority conferred or implied by this Personal Directive and by the Act.
8.2. Without limiting the liability of the agent, the agent is liable for any and all acts and omissions involving intentional wrongdoing, gross negligence or bad faith.
§ 9. TREATMENT DIRECTIONS AND END-OF-LIFE DECISIONS
9.1. Subject to any decision or direction of my agent to the contrary made in accordance with my known wishes and best interests, I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with the directions set out below.
9.1.1. If I have an incurable and irreversible terminal condition that will result in my death within a relatively short time, I direct that:
(a) I be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
(b) I receive tube feeding if necessary, even if such feeding has the effect of prolonging my life;
(c) cardiopulmonary resuscitation be performed if, in the opinion of my attending physician, it is medically indicated; and
(d) should I develop another separate condition that threatens my life, such other condition be given active treatment if, in the opinion of my attending physician, such treatment is indicated.
9.1.2. If I am diagnosed as persistently unconscious and will not regain consciousness, I direct that:
(a) I be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
(b) I receive tube feeding if necessary, even if such feeding has the effect of prolonging my life;
(c) cardiopulmonary resuscitation be performed if, in the opinion of my attending physician, it is medically indicated; and
(d) should I develop another separate condition that threatens my life, such other condition be given active treatment if, in the opinion of my attending physician, such treatment is indicated.
9.1.3. If I am diagnosed as being severely and permanently impaired, I direct that:
(a) I be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
(b) I receive tube feeding if necessary, even if such feeding has the effect of prolonging my life;
(c) cardiopulmonary resuscitation be performed if, in the opinion of my attending physician, it is medically indicated; and
(d) should I develop another separate condition that threatens my life, such other condition be given active treatment if, in the opinion of my attending physician, such treatment is indicated.
9.2. I direct that I be provided at all times with such care, medication and procedures as are required to keep me comfortable, to alleviate pain and to maintain my dignity, whether or not such measures may have the secondary effect of shortening my life.
§ 10. ADDITIONAL WISHES AND INSTRUCTIONS
10.1. I set out the following additional wishes, values, beliefs and instructions to guide my agent and my health care providers: ________.
§ 11. WHEN THIS PERSONAL DIRECTIVE COMES INTO EFFECT
11.1. This Personal Directive comes into effect, and my agent's authority commences, only if and for so long as I am found to lack capacity in respect of the matters to which it relates, in accordance with the Act.
§ 12. DETERMINATION OF CAPACITY
12.1. I name ________ to determine, together with a physician or psychologist, whether I have capacity for the purposes of this Personal Directive.
§ 13. EFFECT OF COPY
13.1. A copy of this Personal Directive has the same legal effect as the original.
§ 14. EXECUTION
14.1. I sign this Personal Directive at ________ (city), in the Province of ________, this ________ day of ________, 20__, in the presence of the witness whose signature appears below.
_______________________________
Signature of Maker
Name: ________
Date: ________
§ 15. WITNESS
15.1. I attest that the maker signed this Personal Directive (or acknowledged his or her signature) in my presence, that the maker appeared to me to understand the nature and effect of this document, and that I am at least 18 years of age. I am not the agent named in this Personal Directive, nor the spouse or adult interdependent partner of the maker or of the agent.
_______________________________
Signature of Witness
Name: ________
Address: ________
Date: ________
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