PERSONAL DIRECTIVE
1. I, ________, currently of ________, in the province of Alberta, make this Personal Directive.
REVOCATION
2. I revoke any previous personal directive made by me.
DESIGNATION
3. I designate ________, currently of ________, to be my agent.
AUTHORITY
4. I give my agent the authority to make any personal care decision for me that I am mentally incapable of making for myself, including the giving or refusing to consent to any matter to which the Personal Directives Act applies, and any instructions, conditions or restrictions contained in this Personal Directive.
5. I give no one, including my agent, any authority to disregard or override my instructions provided in this Personal Directive. Any such disagreement does not diminish the strength or substance of my instructions.
DELEGATION OF AUTHORITY
6. An agent cannot delegate his or her authority as agent.
LIABILITY OF AGENT
7. An agent 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 Personal Directives Act.
8. Without limiting the liability of the agent, the agent will be liable for any and all acts and omissions involving intentional wrongdoing.
TREATMENT DIRECTIONS AND END-OF-LIFE DECISIONS
9. Subject to any decision or direction of my agent(s) to the contrary, I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
a. If I have an incurable and irreversible terminal condition that will result in my death within a relatively short time, I direct that:
I. I will be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
II. I receive tube feeding if necessary, even if such feeding had the effect of prolonging my life;
III. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
IV. Should I develop another separate condition that threatens my life, such other illnesses be given active treatment, if in the opinion of my doctor, such treatment is indicated.
b. If I am diagnosed as persistently unconscious and I will not regain consciousness, I direct that:
I. I will be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
II. I receive tube feeding if necessary, even if such feeding had the effect of prolonging my life;
III. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
IV. Should I develop another separate condition that threatens my life, such other illnesses be given active treatment, if in the opinion of my doctor, such treatment is indicated.
c. If I am diagnosed as being severely and permanently impaired, I direct that:
I. I will be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
II. I receive tube feeding if necessary, even if such feeding had the effect of prolonging my life;
III. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
IV. Should I develop another separate condition that threatens my life, such other illnesses be given active treatment, if in the opinion of my doctor, such treatment is indicated.
IN FORCE
10. This Personal Directive will be in effect only if and as long as I have been found to lack capacity.
SEVERABILITY
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.
EFFECT OF COPY
12. A copy of this Personal Directive has the same legal effect as the original.
Executed at ________________ (city), ________________ (province) this _____ day of ___________, 20__, in the presence of a witness.
_______________________________
Name:
Date:
WITNESS
_______________________________
Name:
Date:
PERSONAL DIRECTIVE
1. I, ________, currently of ________, in the province of Alberta, make this Personal Directive.
REVOCATION
2. I revoke any previous personal directive made by me.
DESIGNATION
3. I designate ________, currently of ________, to be my agent.
AUTHORITY
4. I give my agent the authority to make any personal care decision for me that I am mentally incapable of making for myself, including the giving or refusing to consent to any matter to which the Personal Directives Act applies, and any instructions, conditions or restrictions contained in this Personal Directive.
5. I give no one, including my agent, any authority to disregard or override my instructions provided in this Personal Directive. Any such disagreement does not diminish the strength or substance of my instructions.
DELEGATION OF AUTHORITY
6. An agent cannot delegate his or her authority as agent.
LIABILITY OF AGENT
7. An agent 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 Personal Directives Act.
8. Without limiting the liability of the agent, the agent will be liable for any and all acts and omissions involving intentional wrongdoing.
TREATMENT DIRECTIONS AND END-OF-LIFE DECISIONS
9. Subject to any decision or direction of my agent(s) to the contrary, I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
a. If I have an incurable and irreversible terminal condition that will result in my death within a relatively short time, I direct that:
I. I will be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
II. I receive tube feeding if necessary, even if such feeding had the effect of prolonging my life;
III. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
IV. Should I develop another separate condition that threatens my life, such other illnesses be given active treatment, if in the opinion of my doctor, such treatment is indicated.
b. If I am diagnosed as persistently unconscious and I will not regain consciousness, I direct that:
I. I will be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
II. I receive tube feeding if necessary, even if such feeding had the effect of prolonging my life;
III. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
IV. Should I develop another separate condition that threatens my life, such other illnesses be given active treatment, if in the opinion of my doctor, such treatment is indicated.
c. If I am diagnosed as being severely and permanently impaired, I direct that:
I. I will be kept on artificial life support as long as possible within the limits of generally accepted health care standards;
II. I receive tube feeding if necessary, even if such feeding had the effect of prolonging my life;
III. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
IV. Should I develop another separate condition that threatens my life, such other illnesses be given active treatment, if in the opinion of my doctor, such treatment is indicated.
IN FORCE
10. This Personal Directive will be in effect only if and as long as I have been found to lack capacity.
SEVERABILITY
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.
EFFECT OF COPY
12. A copy of this Personal Directive has the same legal effect as the original.
Executed at ________________ (city), ________________ (province) this _____ day of ___________, 20__, in the presence of a witness.
_______________________________
Name:
Date:
WITNESS
_______________________________
Name:
Date:
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