Make sure that your wishes are followed in case you become physically or mentally incapacitated, with this Personal Mandate in Case of Incapacity, under the Québec Civil Code.
- Use this form to appoint one or more persons to act on your behalf as your personal mandatary to give consent and make decisions regarding medical treatment the event that you become unable to do so.
- You can also give end-of-life instructions on which treatments should be administered to you if you have a terminal illness or are in a permanent coma.
- This is a reusable legal form. Each adult member of your household can prepare a Personal Mandate using the same form - no need to buy multiple copies.
This Quebec Personal Mandate in Case of Incapacity is available as a downloadable English-language form, and is easy to fill in with your personal information. Rich Text Format.
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
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