Alberta Personal Directive Package

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Alberta Personal Directive Package Powered By Docstoc
					                                      PERSONAL DIRECTIVE
THIS PERSONAL DIRECTIVE is given by me, _________________________ [insert name of person making
the directive] of the City/Town of ____________________, in the Province of Alberta, on the _____ day of
__________, ______.

1.      Revocation

I revoke any prior Personal Directive, Living Will or equivalent document made by me.

2.      Appointment of Health Care Agent and Alternate

(a)     I appoint ___________________________ [insert name of agent] of ________________, Alberta, to act
        as my health care agent pursuant to the Personal Directives Act (my “Agent”).
OR
[If you are appointing two or more people to act jointly as your agent, use this paragraph instead.]
(a)       I appoint ___________________________ [insert name of agent] of ________________, Alberta and
          ___________________________ [insert name of agent] of ________________, Alberta to act together
          as my joint health care agents (my “Agents”). This means they must act together on my behalf.
OR
[If you are appointing two or more people to act as joint and several agents, use this paragraph instead.]
(a)       I appoint ___________________________ [insert name of agent] of ________________, Alberta and
          ___________________________ [insert name of agent] of ________________, Alberta to act together
          as my joint and several health care agents (my “Agents”). This means either may act alone
          without the necessity of obtaining any formal written direction or approval from the other. If one
          of my Agents has acted alone he/she must provide details of his/her actions to my other Agents.

[The following paragraph only applies if you are appointing more than one agent. Delete this paragraph if not
appropriate.]
(b)      In the situation where only one of the aforesaid Agents is able to act as my Agent, he or she shall
         have the authority to act or continue to act alone, as my sole Agent.

(c)     On the death, refusal or inability of my Agent so to act or continue to act, I appoint
        ___________________________ [insert name of agent] of ________________, Alberta, to act as my
        alternate health care agent.

3.      Coming Into Effect

(a)     This Personal Directive will be in effect only if and only for as long as I am unable to make or
        communicate my own health care or personal care decisions due to lack of capacity.

(b)     I will be deemed to lack capacity to make or communicate health care or personal care decisions
        when my Agent signs a written declaration to that effect after consulting with a physician or a
        psychologist who has completed a declaration as required by the Regulations to the Personal
        Directives Act (Alberta).

(c)     If my Agent is unable or unwilling to make the determination regarding my capacity, or cannot
        be contacted after every reasonable effort has been made to do so, then a written declaration
        signed by two (2) physicians familiar with my circumstances will be sufficient proof of my
        incapacity.

(d)     It is my wish that my Agent contact the persons listed in the attached Schedule “A” as soon as
        possible, in the event that this Personal Directive comes into effect. I will update Schedule “A”
                                                     -2-

        from time to time to keep it as current as possible. This contact shall be by ordinary mail to the
        addresses in Schedule “A” and no further attempts at contact are necessary.

4.      Method of Making Decisions

(a)     Except where it is inconsistent with the Personal Directives Act (Alberta), my Agent shall act in
        accordance with the provisions of this Personal Directive, provided, however, that if I am able to
        communicate my instructions, either verbally or non-verbally, then this Personal Directive will
        have no effect and my Agent shall follow my instructions.

(b)     If I have not given instructions in this Personal Directive with respect to a particular matter, my
        Agent shall make decisions for me that I would have made for myself, based on my Agent’s
        knowledge of my wishes, beliefs and values.

(c)     If my Agent does not know my wishes, beliefs or values with respect to a particular matter,
        he/she shall make the decision that he/she believes is in my best interests.

[The following paragraphs are only applicable if you have appointed more than one person as your agent. Delete
these paragraphs if they do not apply.]

(d)     Where my Agents are unable to agree on a decision, the decision of ___________________ [insert
        name of agent who will make the decision] shall be deemed to be the final decision.
OR
(d)     Where my Agents are unable to agree on a decision, the decision of a majority of my Agents shall
        be deemed to be the final decision. Any Agent who does not agree with the majority decision
        does not have to accept responsibility for that decision.

(e)     I direct that ________________________ [insert name of designated agent] shall communicate
        decisions on behalf of my Agents.

5.      Authority of Agent

(a)     I hereby grant my Agent the authority to make personal decisions on my behalf when I lack the
        mental capacity to do so. In this Personal Directive, “personal decisions” include any matter of a
        non-financial nature that relates to my person. Personal decisions shall include decisions
        regarding the following matters:

        (i)     health care, including but not limited to the power to:
                A.      consent, refuse or withdraw consent to any type of health care;
                B.      review my medical records and consent to their disclosure to others;
                C.      authorize my admission to or discharge from any medical or care facility;
                D.      obtain health care services on my behalf;
                E.      retain the services of caregivers, and terminate those services;
                F.      sign waivers, releases or permissions required by any person or facility providing
                        health care services to me;
        (ii)    accommodation and living arrangements;
        (iii)   persons with whom I may live and associate;
        (iv)    my participation in social, educational and employment activities;
        (v)     legal matters that do not relate to my estate.

(b)     In addition to the general powers granted above, I specifically authorize my Agent to make
        decisions with regard to the following matters:

        (i)     psychosurgery as defined in the Mental Health Act (Alberta);
                                                         -3-

         (ii)     sterilization that is not medically necessary to protect my health;
         (iii)    removal of tissue from my living body;
         (iv)     or implantation in the body of another living person pursuant to Part 1 of the Human
                  Tissue Gift Act of Alberta; or/and for medical education or research purposes;
         (v)      participation in a reasonable trial of medical research or experimental medical treatment,
                  whether or not my doctor or Agent know the extent of the potential benefit to me.

(c)      I wish to ensure that my resources are used to allow me to live independently for as long as
         possible in my own home or if I must be in institutional care, to ensure that I receive the best
         possible care within my resources. If this depletes all of my resources so that I have no estate left
         when I die, this is acceptable.

6.       Specific Instructions for End-of-Life Treatment

[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 Agent will use (his/her/their) 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
         feeding if it were short-term.

(c)      I want all diagnostic and therapeutic interventions that can be reasonably expected to enable me
         to regain the capacity to make my own decisions. If I am not expected to regain the mental
         capacity to make my own decisions then I want treatment only if it will relieve pain and
         suffering. Comfort care should be given even if the effect would be to shorten my life.

(d)      I do not want to prolong life at all costs. I hereby give authorization for the withholding or
         withdrawal of treatment if my physician and my Agent determine that my death is imminent
         with no reasonable medical expectation of recovery whether or not life sustaining procedures are
         utilized. In addition, I must have lost the ability to interact with others with no reasonable chance
         of regaining that ability. As to what is reasonable, under both the previous statements, shall be
         determined by my attending physician(s).

(e)      Should I be mentally incapable, I do not want to have my life prolonged because everything
         meaningful in life to me will have already passed. In that situation, I refuse consent to
         extraordinary or heroic techniques that artificially maintain a life-sustaining function of my body
         and are used only to prolong my life without improving the chances for cure or reversal of my
         condition. (As to what is extraordinary or heroic shall be determined by my Agent). I request care
         that gives comfort and support, that facilitates my interaction with others to the extent possible,
         and that relieves pain or distress. In case of severe pain, I request that drugs be mercifully
         administered to relieve pain, even if they may hasten the moment of death.
                                                        -4-

7.       Access to Information

[If you wish to restrict your Agent’s access to personal information, use the following paragraph and delete the other
option.]
(a)      My Agent has the right to be provided with all information and records, including medical
         records that are relevant to the personal decision to be made at any given time, or the
         determination of my capacity, as the case may be.

OR
[If you want your Agent to be able to access your personal information without restriction, use the following
paragraph and delete the foregoing option.]
(a)     My Agent has the right to be provided with all information and records including medical
        records that are relevant to me, my medical care, the personal decision to be made at any given
        time, or the determination of capacity, without restriction.

(b)      The following persons may review the record of personal decisions which my Agent is required
         to keep:

         (i)      my spouse and children;

         (ii)     my physician;

         (iii)    any person if my Agent considers to be in my best interest that such person should be
                  aware of the personal decisions.

(c)      The following persons may not have access to the record of personal decisions which my Agent is
         required to keep: [list anyone that you want to prohibit from having access to such information]

(d)      I specifically direct that ____________ [insert name(s)] shall not receive any information about me
         or my health care or personal decisions and shall have no input into my personal decisions.

8.       Conditions and Restrictions

This Personal Directive is subject to the following conditions or restrictions:

[Choose the Power of Attorney clause that fits your wishes. Even if you don’t have a Power of Attorney at present,
you should keep this provision in the document, in the event that you do execute a Power of Attorney in future.]
(a)     Power of Attorney: I may also have an Enduring Power of Attorney (EPA) that is in effect or that
        is to take effect at such time as I lose mental capacity. In that situation I direct that my Agent and
        my Attorney appointed under that EPA are to work together to give effect to my instructions
        under both this Personal Directive and my EPA. In the situation where my instructions conflict or
        are ambiguous I direct that my Agent is to have the final decision making power and my
        Attorney shall follow my Agent’s directions, allowing funds to be made available to implement
        those decisions.
                                                         OR
(a)     Power of Attorney: I may also have an Enduring Power of Attorney (EPA) that is in effect or that
        is to take effect at such time as I lose mental capacity. In that situation I direct that my Agent and
        my Attorney appointed under that EPA are to work together to give effect to my instructions
        under both this Personal Directive and my EPA. I direct that my Agent is to report regularly to
        my Attorney with respect to decision that are made under this Personal Directive.
                                                         OR
 (a)    Power of Attorney: I may also have an Enduring Power of Attorney (EPA) that is in effect or that
        is to take effect at such time as I lose mental capacity. In that situation I direct that my Agent and
                                                     -5-

        my Attorney appointed under that EPA are to work together to give effect to my instructions
        under both this Personal Directive and my EPA. In the situation where my instructions conflict or
        are ambiguous I direct that my Agent and my Attorney shall work together to make decisions
        that are in my best interests, having regard to all of the circumstances, including the size of my
        estate and my income requirements. In the event of a dispute that cannot be resolved, I direct that
        my Agent and my Attorney, together with any other family members who are involved, attend
        before a mediator prior to making a Court application to resolve the dispute.

[The following Monitoring provisions can be edited to fit your specific wishes.]
(b)       Monitoring: I direct my Agent to seek input from _______________________________ [insert
          specific names or indicate persons such as “all of my children”} before making any decisions on my
          behalf that are of an unusual or permanent nature. It is not my intention that my Agent seek input
          on ordinary day to day matters. In all situations my Agent shall retain absolute discretion to make
          all decisions in his/her capacity as my Agent.
                                                         OR
 (b)      Monitoring: In the event that my spouse fails to survive me, or is not able to act as my Agent, I
          direct my alternate Agent to seek input from _______________________________ [insert specific
          names or indicate persons such as “all of my children”} before making any decisions on my behalf that
          are of an unusual or permanent nature. It is not my intention that my alternate Agent seek input
          on ordinary day to day matters. In these situations my alternate Agent shall retain absolute
          discretion to make all decisions in his/her capacity as my Agent.
                                                         OR
 (b)      Monitoring: I specifically direct that _______________________________ [insert specific names or
          indicate persons such as “all of my children”} be consulted on all important decisions made by my
          Agent resulting in a change in circumstances, particularly decisions that affect my level of care
          and comfort or that could have the effect, directly or indirectly, of shortening my life. In all
          situations my Agent shall retain absolute discretion to make all decisions in his/her capacity as
          my Agent.
                                                         OR
 (b)      Monitoring: In the situation where my children are acting as my joint and several Agents, I
          specifically direct that they all be involved in all important decision, particularly decisions that
          affect my level of care and comfort or that could have the effect, directly or indirectly, of
          shortening my life.
                                                         OR
 (b)      Monitoring: In the situation where my children are acting as my joint Agents and are unable to
          make a decision on my behalf, I would like them to seek assistance to reach a consensus by
          consulting with available resources such as ethics committees, pastoral care workers, social
          workers or any others that the Agents trust.
                                                         OR
 (b)      Monitoring: In the situation where ______________________________ [insert name of person] is
          acting as my Agent and must make a decision that will affect my level of care and comfort or that
          could have the effect, directly or indirectly, of shortening my life, I direct that my Agent call a
          family meeting with the family being defined as _________________________ [list the family
          members to be included in the family meeting], and make a decision the whole family agrees to.
          Where the family is unable to agree on a decision, my Agent shall retain absolute discretion to
          make all decisions in his/her capacity as my Agent.

[Choose the Reporting provision that fits your wishes, or add your own.]
(c)      Reporting: I direct my Agent to prepare a [monthly / quarterly / annual] report, showing in
         detail the decisions made on my behalf within the time period of the report. My Agent shall
         provide a copy of this report to:
                                                      -6-

        [list the people who are to get a copy of the report, such as “my spouse”, my children”, etc., and you can
        also add specific names for others who are to get the report]




                                                 OR
(c)     Reporting: In the event that my spouse fails to survive me, or is not able to act as my Agent, I
        direct my alternate Agent to prepare a [monthly / quarterly / annual] report, showing in detail
        the decisions made on my behalf within the time period of the report, and to provide a copy of
        this report to:

        [list the people who are to get a copy of the report, such as “my spouse”, my children”, etc., and you can
        also add specific names for others who are to get the report]




                                                   OR
(c)     Reporting: In the situation where my children are acting as my joint and several Agents and any
        of my children has acted alone, I direct that child to provide an informal report (which can be
        verbal) to my other children, detailing his/her actions on a regular basis. This should take place
        at least once a month.

[You can use the “Other” paragraph to add provisions covering any other restrictions or conditions, such as
circumstances when your Agent does not have authority to make personal decisions for you. If you don’t wish to add
anything further, delete paragraph (d).]
(d)     Other:

9.      Remuneration of Agent

[Set out how you want your Agent to be remunerated for acting on your behalf.]
The remuneration of my Agent shall be determined by ______________________ [insert name of person
making determination] based on the assistance provided by my Agent and the costs that would have been
involved in hiring other care to provide these services. In addition, my Agent shall be entitled to
immediate reimbursement for any and all out-of-pocket expenses that he/she shall incur in his/her
capacity as my Agent, including any expenses incurred to travel to where I am living in order to take care
of my personal decisions.
                                                     OR
My Agent shall not be entitled to any fee or compensation for acting as my Agent, however, he/she will
be entitled to reimbursement for any and all out-of-pocket expenses that he/she shall incur in his/her
capacity as my Agent, including long distance telephone charges relating to estate affairs, and any
expenses incurred to travel to where I am living, in order to take care of my personal decisions.

10.     Schedules

This Personal Directive includes the attached schedules “A” and “B”.

IN WITNESS WHEREOF I have hereunto set my hand and seal at ____________, _________, this _____
day of _________, _______.

SIGNED, SEALED and DELIVERED
in the presence of:
                                        -7-

                                       ____________________________________
                                       Signature of Maker
____________________________________
Signature of Witness

____________________________________
Print Name

____________________________________
Signature of Witness

____________________________________
Print Name
                                                     -8-

                              CERTIFICATE OF LEGAL ADVICE

I, [lawyer], Barrister & Solicitor, practicing in the City of _____________, in the Province of Alberta, do
hereby certify that:

1.      On the _____ day of ________ , ______, _________________________ (hereinafter referred to as the
        “Maker”), attended before me concerning the Personal Directive;

2.      The Maker appeared to me to understand the nature and effect of the Personal Directive;

3.      I am satisfied that the Maker was of the full age of Eighteen (18) years on the date the Maker
        signed the Personal Directive;

4.      The Maker signed the Personal Directive, or acknowledged the Maker’s signature in my presence;

5.      The Maker acknowledged to me that the Maker gave the Personal Directive voluntarily;

6.      I am satisfied by examination of the Maker that the Maker understood the explanatory notes
        attached to the Personal Directive;

7.      I am not the Agent nor the spouse to the Agent named in the Personal Directive.

DATED at ____________________, Alberta this _____ day of ______________, _______.




                                         Signature of Lawyer


                                         Print Name of Lawyer

                                         Law Firm:

                                         Address:


                                         Phone No.:
                                                   -9-

                                   AFFIDAVIT OF EXECUTION

CANADA                                    I, ___________________________________________,
                                          of the City of _________________, in the Province of Alberta,
PROVINCE OF ALBERTA
                                          MAKE OATH AND SAY THAT:
TO WIT:


1.     ____________________________ and I are               both    witnesses   to   the   signature   of
_________________________ in this Personal Directive.

2.      ____________________________ and I were both present and saw _________________________
sign and seal this document at _______________________, Alberta.

3.       On the basis of identification, I believe _________________________ to be the person named in
this Personal Directive.

4.       Neither ____________________________ nor I are named as an Agent, nor are we the spouse of a
person named as an Agent, nor are we the spouse of _________________________, the person named in
this Personal Directive.

5.      I believe _________________________ is at least 18 years of age.

SWORN BEFORE ME at the City of __________,
in the Province of Alberta, this
_____ day of ______________, _______.                    __________________________
                                                         Signature of Deponent



_____________________________________
A Commissioner for Oaths in and for the
the Province of Alberta

My commission expires:
                                                  - 10 -

                            SCHEDULE “A”
        TO PERSONAL DIRECTIVE OF ________________________ [insert name]


  FAMILY MEMBERS AND OTHER INTERESTED PERSONS THAT MY AGENT
                    MAY NEED TO CONTACT
(Note: Please keep the information on this Schedule up to date)

                     SPOUSE                                            PHYSICIAN
Name:                                                 Name:

Address:                                              Address:


Phone Nos:                                            Phone Nos.:

                   CHILDREN                            ATTORNEY IN MY ENDURING POWER OF
                                                                   ATTORNEY
Name:                                                 Name:

Address:                                              Address:


Phone Nos:                                            Phone Nos.:

                                                                         LAWYER
Name:                                                 Name:

Address:                                              Address:


Phone Nos:                                            Phone Nos.:

                                                                      ACCOUNTANT
Name:                                                 Name:

Address:                                              Address:


Phone Nos:                                            Phone Nos.:

                                                                    SPIRITUAL ADVISOR
Name:                                                 Name:

Address:                                              Address:


Phone Nos:                                            Phone Nos.:
                                   - 11 -

        OTHER INTERESTED PERSONS                       DENTIST
Name:                                  Name:

Address:                               Address:


Phone Nos:                             Phone Nos.:

                                               OTHER MEDICAL RESOURCES
Name:                                  Name:

Address:                               Address:


Phone Nos:                             Phone Nos.:


Name:                                  Name:

Address:                               Address:


Phone Nos:                             Phone Nos.:
                                                  - 12 -
				
DOCUMENT INFO
Description: If you're an Alberta resident, you can make a Personal Directive with this easy-to-use package. A Personal Directive ensures that your wishes are followed in the event that you become physically or mentally incapacitated. It is also called an advance health care directive or a living will. In a Personal Directive, you appoint an agent - someone you trust - to act on your behalf, and you can give your agent detailed instructions and set out your wishes regarding medical care, living conditions, personal and legal matters. This Package contains: - Personal Directive form, - instructions on how to complete the form, - Declaration of Incapacity forms, - frequently asked questions about personal directives, - a Personal Directive Questionnaire, which should be filled out first to help you prepare your Directive. This Alberta Personal Directive Package is available in MS Word format, and is easy to use and understand. Making a Personal Directive gives you and your family peace of mind.
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