PERSONAL DIRECTIVE
of ____________________

I, ____________________ (the "Maker"), of ______________________________________________________________, phone: __________, being of sound mind and at least 18 years of age, make this Personal Directive fully understanding the consequences of my action in doing so. I intend this Personal Directive to be read by my health care providers, family and friends as a true reflection of my wishes and instructions should I lack Capacity and be unable to communicate such wishes and instructions.

1. Definitions
   
1. As used in this document:
   
   1. "Act" means the Alberta Personal Directives Act.
      
   2. "Capacity" means the ability to understand the information that is relevant to the making of a personal decision and the ability to appreciate the reasonably foreseeable consequences of the decision.
      
   3. "Cardiopulmonary resuscitation" means restoration of heartbeat and breathing following cardiac arrest, using artificial respiration and external cardiac massage.
      
   4. "Comfort care" means treatment, including prescription medication, provided to the patient for the sole purpose of alleviating pain and discomfort.
      
   5. "Health care provider" means any person licensed, certified or otherwise authorized by law to administer health care in the ordinary course of business or practice of a profession.
      
   6. "Life support" means any medical procedure, treatment or intervention which sustains, restores or supplants a spontaneous vital function. In this document the term does not include tube feeding or the provision of medication or the performance of a medical procedure when such medication or procedure is deemed necessary to provide comfort care or to alleviate pain.
      
   7. "Persistently unconscious" means being in a profound state of unconsciousness caused by disease, injury, poison or other means from which there exists no reasonable expectation of regaining consciousness.
      
   8. "Severely and permanently mentally impaired" means being in a permanent and irreversible state of mental impairment in which there is:
      
      1. The absence of voluntary action or cognitive behaviour; and
         
      2. An inability to communicate or interact purposefully with the environment.
         
   9. "Terminal condition" means a condition caused by injury, disease or illness from which there is no reasonable medical probability of recovery and which, without treatment, can be expected to cause death.
      
   10. "Tube feeding" means the provision of nutrients or fluids by a tube inserted in a vein, under the skin in the subcutaneous tissues, or in the stomach (gastrointestinal tract).
       
2. Revoke Previous Personal Directive
   
2. I revoke any previous Personal Directive made by me.
   
3. Designation of Agent
   
3. I do not wish to designate an Agent, but provide the following information and instructions to be followed by a service provider who intends to provide personal services for me.
   
4. Notwithstanding the previous clause, I give no one (including my Agent) any authority to disregard or override my instructions provided in this Personal Directive. Family members, relatives, friends may disagree with me, but any such disagreement does not diminish the strength or substance of my instructions.
   
5. Treatment Directions and End-Of-Life Decisions
   
5. I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
   
   1. If I have an incurable and irreversible terminal condition that will result in my death within a relatively short time, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   2. If I am diagnosed as persistently unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   3. If I am diagnosed as being severely and permanently mentally impaired, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
6. Revocation
   
6. The authority granted in this Personal Directive may be revoked as and where permitted by law.
   
7. I understand that, as long as I have Capacity, I may revoke this Personal Directive at any time.
   
8. Statement of Values and Beliefs
   
8. ________________________________________________________________________________________________________________________.
   
9. General
   
9. A copy of this Personal Directive has the same effect as the original.
   
10. 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. But if the intent of this Personal Directive would be substantially changed by such construction, then it shall not be so construed.
    
11. This Personal Directive is intended to be governed by the laws of the Province of Alberta.
    

Signature

Signed by me under hand and seal in the presence of my witness in the Province of Alberta, this ________ day of ________________, ________.

Record of Copies
Record of people and institutions to whom I have given a copy of this Personal Directive:

General comments regarding your Personal Directive

1. Read the entire document before you sign in the space provided. Make sure it says what you want it to say.
   
2. Do not leave any blank lines above your signature to be filled in after signing. Make sure there are no blank lines before you sign.
   
3. Each page should be numbered. (e.g. 1 of 3, 2 of 3, etc.)
   
4. You and your witness should initial all the pages.
   

Signing requirements for your Alberta Personal Directive

- A Personal Directive must be signed by the Maker in the presence of a witness.
               - Where the Maker is physically unable to sign, it must be signed by another person on behalf of the Maker, at the Maker's direction and in the presence of both the Maker and a witness. (A person designated in the directive as an Agent or the spouse or adult interdependent partner of an Agent cannot sign on behalf of the Maker).
               - A Personal Directive must be signed by the witness in the presence of the Maker.

Limitations to the authority of your Agent

An agent has no authority to make personal decisions relating to the following matters unless the maker's personal directive contains clear instructions authorizing the agent to do so:
               - psychosurgery as defined in the Mental Health Act;
               - sterilization that is not medically necessary to protect the maker's health;
               - removal of tissue from the maker's living body for implantation in another person or for medical research and education;
               - participation by the maker in research or experimental activities where there is little or no benefit to the maker; or
               - anything else prohibited by regulation.