Quebec Personal Mandate in Case of Incapacity - DOC by Megadox

VIEWS: 36 PAGES: 4

More Info
									                   PERSONAL MANDATE IN CASE OF INCAPACITY
This Personal Mandate made by:


Name:     __________________________________________________ [give full name]

Address: __________________________________________________ [give full address]
         _______________________, Québec

Date of birth: __________________               Phone: (_______) _________________

1.      Appointment of Personal Mandatary

I appoint the following person as mandatary of my person pursuant to the Civil Code of Québec:

        Name:                   ________________________________________________________________

        Address:                ________________________________________________________________

        Phone Number:           ________________________________________________________________

2.      Substitute Mandatary

If my mandatary dies or is otherwise unable or unwilling to act for any reason, I appoint the following
person as substitute mandatary of my person in his/her place:

        Name:                   ________________________________________________________________

        Address:                ________________________________________________________________

        Phone Number:           ________________________________________________________________

3.      Coming Into Force

This Personal Mandate only comes into force when it is homologated by order of the appropriate Court.

4.      Authority and Duties of Personal Mandatary

(a)     General Matters:

        (i)     My personal mandatary shall have sole power and authority to make all decisions
                necessary to ensure my personal protection and to provide for my mental and physical
                well-being without limitation.

        (ii)    I direct my mandatary at all times when acting under this Mandate to respect my values
                and beliefs, my ability to make decisions for myself, and the standard of living I enjoyed
                before I became incapacitated.

(b)     Consent to Treatment:

        If I am unable or unwilling to consent to treatment required by my state of health, I give my
        mandatary power to do so on my behalf. He/she must make an informed decision based on the
        risks and benefits of the treatment in question.
                                                         -2-



                                             ____________       ___________       __________
                                                      (initials of mandator and witnesses)

(c)      Access to Personal Information:

         I give my mandatary authority to consult any records containing personal information about my
         health and my personal affairs, including my medical and social records.

(d)      Reporting:

         I direct my mandatary, once each year on the anniversary of the date he/she began to act under
         this Mandate, to file a report of his/her activities during the foregoing year with
         __________________________________ [the name of the person with whom the report is to be filed].

5.       Instructions for End-of-Life Treatments

[Read this section carefully and choose only the clause(s) that fit with your wishes. Delete the others. Alternatively,
if none of these examples reflect your wishes, add your own clauses.]
I give the following instructions with the expectation that my mandatary will use his/her own good
judgment in making decisions, given the circumstances at the time, taking into consideration the
following guidelines wherever possible:

(a)      In the event of a catastrophic illness for which there is no cure, I would like comfort measures
         only, including surgery if needed, to relieve symptoms. I wish to be treated only for relief of
         distress, and not to prolong life. I want to stay at home if possible, with transfer to hospital only if
         absolutely necessary.

(b)      In the event of a mild stroke or mild dementia, I would like all major treatments, such as CPR, life
         saving surgery or antibiotics to continue, but would only want a ventilator, dialysis or tube
  
								
To top