INSTRUCTIONS FOR PERSONAL DIRECTIVE
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A Personal Directive will give your Agent the right to make decisions on your behalf regarding your medical care or health decision should you lose mental capacity. You can include instructions that you want followed (eg. refuse blood products), as long as it does not include anything illegal, such as assisted suicide or euthanasia. The need for a personal directive may be short-term, such as when a serious illness leaves you unable to make decisions for a few days. However, in the event of serious brain injury or a progressive condition like Alzheimer’s Disease, a personal directive may be required for the remainder of your life. Unlike a Will, which takes effect after you die, a personal directive guides personal decisions that are made on your behalf while you are still living – when you can no longer make decisions on your own.
Your Agent should be someone you know and trust completely. Your Agent must be 18 years of age at any time while the Personal Directive is in effect and your agent must have the capacity to make personal decisions on your behalf. This Personal Directive will take effect only when you lack capacity with respect to your medical care or health decisions. You will be determined to lack capacity when you are unable to communicate your own decisions by speaking, writing, or gesturing; or in the opinion of at least two medical doctors you no longer have the requisite mental capacity to make competent decisions about your personal care and treatment.
If you have named someone as the sole beneficiary of your Estate in your Will, it may be preferable to name him/her as the primary Agent. You should also name alternates, in the event your first choice is unable to act. For tax reasons, it is not advisable to choose an Agent who resides outside of Canada. If you have more than one Agent, it would be preferable if at least one of them is a resident of Alberta.
Personal Directive Questionnaire
- Name an agent (This is the person or persons that will make decision for you if you should lose the capacity of make them for yourself.)
Full Name: _____________________________________________________________
Relationship: ________________________________________ Age: ______________
Address: _______________________________________________________________
Phone/fax/email: ________________________________________________________
- If you want more than one agent to act together (joint agents), name the other agent or agents here:
Full Name: _____________________________________________________________
Relationship: ________________________________________ Age: ______________
Address: _______________________________________________________________
Phone/fax/email: ________________________________________________________
Full Name: ____________________________________________________________
Relationship: ________________________________________ Age: ______________
Address: _______________________________________________________________
Phone/fax/email: ________________________________________________________
- If you are naming more than two agents, do they make decisions on a majority basis or do they all have to agree?
o On a majority basis
o They all have to agree
- If you are not naming joint agents and your first-named attorney can not or will not act, name your second choice here:
Full Name: ____________________________________________________________
Relationship: ________________________________________ Age: ______________
Address: _______________________________________________________________
Phone/fax/email: ________________________________________________________
- If your second-named agent can not or will not act, name your third choice here:
Full Name: ____________________________________________________________
Relationship: ________________________________________ Age: ______________
Address: _______________________________________________________________
Phone/fax/email: ________________________________________________________
- Indicate who should decide whether or not you have lost the capacity to make decisions about any personal matter:
o One doctor
o Two doctors:
_____________________________________Together with:
o One doctor or
o Two doctors
o Other:
Full Name: ____________________________________________________
Relationship: ______________________________ Age: _______________
Address: _____________________________________________________
Phone/fax/email: _______________________________________________
- Do you want to donate your organs and tissue for transplantation purposes if at the time of your death your have any that would be useful for this purpose?
o Yes
o No
- What are your views about being kept alive artificially if there is no known hope of recovery?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________