Introduction
Planning for the future is important. You should think about who you would want to make decisions
for you if you are not capable (temporarily or permanently) to make them yourself. You should
think about what kinds of decisions should be made for you and how they should be made.
To get ready for the future, think about preparing:
(1) An Enduring Power of Attorney that allows you to appoint someone to look after your
money, property and financial affairs when you are not mentally capable of making
financial and property decisions, or if you wish them to assist you with your financial
affairs when you are still capable. It is only in effect when you are alive.
(2) A Personal Directive that allows you to set out how personal care decisions, including
health care decisions, are to be made for you when you are not mentally capable of
making those decisions. It is only in effect when you are alive and mentally incapable
of speaking for yourself.
(3) A Will that allows you to set out how you want your personal, property and financial
assets handled after you die. A Will takes effect when you die.
This document provides information about Personal Directives only. For information about
Enduring Powers of Attorney and Wills, speak with a lawyer, tax advisor or financial planner.
Getting Started
It is important for everyone to have a Personal Directive. We can lose our mental capability
temporarily or permanently. We can lose our mental capability slowly, such as with
Alzheimer’s Disease, or very suddenly, as a result of a car accident. Preparing a Personal
Directive gives you a voice in the care you will receive if you cannot make your own decisions
at the time. It also helps those who will have to make personal care decisions for you. It may
be the best gift you can give to your loved ones who may have to make difficult decisions
for you in the future.
It is important to talk about these issues with the people you trust—your family, friends,
health care providers and spiritual advisors. Filling out a Personal Directive can be a way of
sorting out your values, fears, hopes and wishes about how you want to live. It may take some
time and help from others but it can be a very positive journey. In picking up this form,
you have made the first step.
The Government has prepared related materials that you may wish to read before you
prepare a Personal Directive. These materials are available at
www.gov.ns.ca/just/pda .
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Personal Directives in Nova Scotia
Making a Personal Directive
Information and Sample Form
These materials include:
•
Planning for Your Future Personal Care Choices – this is a brochure that provides
general information about Personal Directives
•
Personal Directives in Nova Scotia – this is a booklet that provides general,
but detailed, information about Personal Directives
•
Making a Personal Directive: Information and Sample Form [this is the document you
are reading now] – the document walks you through how to fill out the sample
Personal Directive form and highlights choices for you to consider
•
Naming a Delegate Only in a Personal Directive: Information and Sample Short Form –
the document walks you through how to fill out a Personal Directive when the only
thing you want to do is name one person to make decisions for you
A Personal Directive is a legal document under the Personal Directives Act that allows you to:
•
name a person [called a “delegate”] you trust to make personal care decisions for you
when you are not capable of making these decisions;
•
write down instructions or other information about what or how personal care decisions
should be made for you when you are not capable of making these decisions; or
•
do both of the above (name a delegate and set out instructions/information).
Personal care decisions are decisions that relate to such things as health care, nutrition,
hydration, shelter, residence, clothing, hygiene, comfort, recreation, social activities and
support services. They do NOT include financial decisions. To appoint a person to make
financial decisions you will need to prepare an Enduring Power of Attorney.
Your Personal Directive needs to be written, dated, signed by you and witnessed by an adult.
If you are not physically able to complete the form, you may direct another person to fill it out
for you. You do not have to use the attached form (or the Naming a Delegate Only form),
but you may wish to look at it and the materials referenced above because they highlight
issues you should think about when writing a Personal Directive.
Your Personal Directive is only in effect when you are not capable of making decisions for
yourself. You may be incapable temporarily or permanently.
You do not need a lawyer to write a Personal Directive, but you may wish to speak with
a lawyer about it when you are discussing other planning tools (such as an Enduring
Power of Attorney and a Will).
Each section in the attached Personal Directive form is optional. It is your choice whether
to fill in a given section. You may choose to fill in only one section, or you may choose to
fill in many sections. Please initial beside each item to confirm this is your choice. Your
witness should also initial beside the item.
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Instructions for Completing a Personal Directive Sample Form
Name
I, __________________________________________________, make this Personal Directive.
Name of Maker
Print your name here. You are the maker of this Personal Directive and will be referred to
as the maker for the rest of the form.
To make a valid Personal Directive you must be capable of understanding the nature and
effect of your Personal Directive. That means that you understand what you have put in your
Personal Directive and the consequences of your choices. There is no age requirement for
writing a Personal Directive.
1. Consultation when assessing capacity(optional)
Your Personal Directive only takes effect when you are not capable of making your own care
decision (when you are not able to understand the nature of the decision to be made and the
consequences of your choice). Your health care provider will determine whether you demonstrate
an understanding of the proposed care, the risks and benefits, the alternatives, etc. This happens
every time services are provided to a patient/client and is part of obtaining informed consent.
Determining capacity can be complex and sometimes it may be helpful for the health care
provider to speak with someone who knows you well. You may identify someone by name
(for example, Jane Smith), title or position (for example, my parish priest) with whom you
would like your health care provider to speak.
2. Revoking (Cancelling) Other Personal Directives (optional)
If you have never written a Personal Directive before, go to section 3.
Section 2 allows you to revoke (cancel) previous Personal Directives.
The Personal Directives Act allows you to have more than one Personal Directive so long as
they deal with different types of decisions. For this reason, there are two options for revoking
or cancelling previous Personal Directives. This section allows you to:
(1) revoke all previous Personal Directives or
(2) revoke only certain previous Personal Directives, allowing the other(s) to remain
in effect. Enter the date and a brief description of the previous Personal Directive(s)
that is being revoked.
Initial the appropriate option to indicate you agree with this revocation. Initial beside only
one of the options.
It is a good idea to review your Personal Directive every year, whenever you or your delegate
have a significant change in your health, or when you experience a significant event in your
life such as the death of a loved one, a marriage or a divorce.
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3. Authorization to Act as Delegate (optional)
A delegate is someone you name to make personal care decisions (including health care
decisions) for you when you are not capable to make these decisions. The delegate must be
at least 19 years old (unless they are your spouse). They do not have to live in Nova Scotia as
long as they can be contacted.
There are two options under section 3. Choose only one of the options if you decide to
complete this section.
(1) You may name one person to act as your delegate and make any personal care
decision that you are not capable to make.
You may choose to name an alternate delegate to make decisions when the delegate
named before is unable or unwilling to make a decision. If you choose not to name an
alternate delegate, it is advisable to place a line through the space provided for naming
an alternate delegate.
(2) You may choose different people to act as your delegates for different decisions.
Each person named will be able to make decisions only for the type of decisions
identified in your Personal Directive.
You may choose to name an alternate delegate to make decisions when each delegate
named before is unable or unwilling to make a decision. If you choose not to name an
alternate delegate, it is advisable that you place a line through the space provided for
naming an alternate delegate.
Your delegate should be someone who:
•
knows you very well
•
is trustworthy
•
is willing to respect your views and values
•
is able to make difficult decisions in stressful circumstances and who you trust
to speak for you
Sometimes a spouse or family member is the best choice. Sometimes they may not be
the best choice because they may be too emotionally involved. Only you know what is best
for your particular circumstances. Talk over your wishes with your delegate(s) and make sure
they will respect your wishes, even if your wishes conflict with your delegate’s wishes.
If your delegate does not know your wishes, they will make decisions based on your values
and beliefs. If they don’t know your values and beliefs, they will make decisions that are in
your best interests. When deciding what is in your best interests, the delegate needs to consider
whether consenting or refusing consent will improve or deteriorate your condition; whether
it is the least restrictive option; and what are the risks and benefits of consenting or refusing
to consent.
If you decide not to name a delegate and you do not provide specific instructions under
section 5 of the sample form about the decision to be made, a person authorized under
the Personal Directives Act may be asked to make the decision on your behalf. These people
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are called statutory decision-makers and they may only make decisions about your health
care, placement in a continuing care home, and home care services. The people in the list
below are potential “statutory decision-makers”. A care provider will start at the top and
work their way down the list until they find an adult who has been in contact with you over
the previous year and is willing to make the decision.
•
spouse (includes married, common law, registered domestic partners)
•
child
•
parent
•
person who stands in the place of a parent
•
sibling
•
grandparent
•
grandchild
•
aunt or uncle
•
niece or nephew
•
other relative
If there is no one from that list available or willing to make the decision, the Public Trustee’s
office will be contacted. A stranger may not be the person you wish to make your decisions.
Your statutory decision-maker will make decisions based on your values and beliefs. If they
don’t know your values and beliefs, they will make decisions that are in your best interests.
When deciding what is in your best interests, the statutory decision-maker needs to consider
whether consenting or refusing consent will improve or deteriorate your condition; whether
it is the least restrictive option; and what are the risks and benefits of consenting or refusing
to consent.
If you choose to name a delegate, go to section 5.
If you choose not to name a delegate, go to section 4.
4. No Delegate Authorized (optional)
You may decide that you do not want to name a delegate but you do want your care providers
to follow specific instructions. By completing section 4, you are telling care providers that your
instructions should speak for themselves and the care providers can rely on them without
needing to get the consent of another person. You will write down your instructions in the
next section of the sample form (section 5). Talk about your instructions with your care
providers, including health care providers, to ensure your instructions reflect your wishes
and to ensure they understand what you want.
It is important to know that it is very difficult to write down instructions that cover every
situation. If your instructions are not relevant to the decision to be made or if they are not clear,
the care provider may need to talk with a statutory decision-maker and ask them to make the
decision on your behalf. In these circumstances, the statutory decision-maker would be guided
by what you wrote down and make the decision they think you would have wanted.
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5. Specific Instructions (optional)
You may write down specific instructions that you want your delegate to follow, or if you
have not named a delegate, that you want your care providers to follow. For example, you
may decide to write down instructions about a medical treatment you would or would not
want in certain circumstances. For instructions relating to health care, you should talk with
your health care provider so they can provide you with accurate information about health
conditions and treatment options. It is important to be informed before you decide what
instructions to write down. At the end of these Instructions for Completing a Personal Directive
(Long Form), there is a list of words that relate to personal care choices (including health care).
These may help you think about some of the possible choices you may want to consider.
When you write down your instructions, it is very important that you express them clearly
and identify the situations where you expect the instructions to be followed. Your delegate
or care providers can only follow instructions that are clear (everyone would agree on what
you mean) and that apply to your circumstances at the time the decision is made. Some
examples of what you might want to express in this section include:
•
My faith affiliation is such that I would not want a blood transfusion under
any circumstances
•
If I have a severe stroke [see information that follows these Instructions] and cannot
maintain an acceptable quality of life [you need to say what ‘acceptable quality of life’
means to you here or in section 6] I do not want anyone to attempt to or continue to
resuscitate me if I have no pulse and am not breathing
•
If I can give a family member an organ and still maintain an acceptable quality
of life [you need to say what ‘acceptable quality of life’ means to you here or in
section 6] then I want to donate the organ while I am still alive
Remember that you can fill out both section 5 (specific instructions) and section 6 (other
information). If your instructions are unclear or do not apply to the situation, your delegate
or statutory decision-maker will make decisions based on your values and beliefs. If they don’t
know your values and beliefs, they will make decisions they believe are in your best interests.
6. Other Information (optional)
You may write down general information that you think will help your delegate or statutory
decision-maker when it comes time to make personal care decisions (including health care)
on your behalf. You can write down specific instructions (under section 5) and general
information under this section of the Personal Directive.
It is impossible to anticipate every situation. It may be most useful if you express your basic
personal values and beliefs about your life and future care and leave the specific decisions
up to your delegate or statutory decision-maker. You should think about your religious beliefs,
cultural preferences or other information that will help guide your delegate or statutory decision-
maker when they make decisions for you in the future. What you write down should reflect YOUR
personal values, beliefs and wishes, and should identify what is important to YOU. Talk to your
delegate and loved ones about this. Some examples of what you might want to express in your
Personal Directive include:
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•
what you would consider to be an acceptable quality of life (think about such things as:
*recognize family and friends *communicate *feed myself *take care of myself
*be conscious and aware of my surroundings and people *live in my own home
*breathe on my own without assistance from a ventilator)
•
your views about admission to a continuing care home if necessary
•
whether you prefer to stay at home as long as this does not cause undue stress
on your family and caregivers
•
your values and beliefs about sexual activity
•
your values and beliefs about what you eat
•
your preferences around social activities
•
whether you want everything possible done to maintain life
•
whether your religious beliefs are important to you and because of this
you have certain wishes
•
if you are nearing death, what you would want or not want to happen
•
whether you would want to die at home if possible
Your wishes will be respected as long as they apply to the situation and they are
possible to comply with. For example, it may not be possible to comply with your wish to
never live in a continuing care home if your physical care needs become too much for your
family and home care services. Current administrative processes will be followed consistently
whether you are making the decision yourself or if the preference is expressed in a
Personal Directive.
Health care decisions are complex and it is helpful to think of them in two general contexts:
(1) situations where you have a condition that you will recover from and
(2) situations where you have a condition that is life threatening or irreversible
and unacceptable to you.
You may want to list your health care wishes under these two general contexts. For example,
you may want to say something like:
“If I have a condition that is reversible or where I can achieve an acceptable quality of life
[and you have described what ‘acceptable quality of life’ means to you], I want the following:
e.g., all necessary health care including life saving treatment; or all necessary health care except…”
“If I have a condition that will cause me to die soon or a condition (including substantial brain
damage or brain disease) where there is little reasonable hope that I will regain a quality of life
acceptable to me [and you have described what ‘acceptable quality of life’ means to you], I want
the following: e.g., resuscitation; comfort measures only; specific treatments if recommended by
my health care providers e.g., antibiotics, kidney dialysis; transfer to a hospital if necessary; all
necessary health care to prolong my life…”
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At the end of these Instructions there are descriptions of some of the more common health
conditions and treatments that many people think about when planning for their future
health care decisions and making their Personal Directive. Talk to your health care provider
about your current health condition and future treatment options.
7. Instructions about Statutory Decision-makers (optional)
You may decide that you do not want to name a delegate and that you are comfortable with
having your nearest relative act as your statutory decision-maker, but there is a relative(s) in
the following list that you would NOT want to make decisions for you. If so, you can put that
information in your Personal Directive.
•
spouse (includes married, common law, registered domestic partners)
•
child
•
parent
•
person who stands in the place of a parent
•
sibling
•
grandparent
•
grandchild
•
aunt or uncle
•
niece or nephew
•
other relative
8. Consultation when Delegate Making Decision (optional)
If you fill out this section, you must name a delegate.
Sometimes there may be more than one person that you want to be involved in making
a decision about your personal care (including health care). Where you name a delegate,
only your delegate can make the decision on your behalf, but you can direct your delegate
to talk with certain people (e.g., family, friends, spiritual advisor) before making a final decision.
This can be helpful to inform your delegate and help them make the decision on your behalf.
9. Notification (optional)
You can decide if you want certain people told, or not told, when your Personal Directive
becomes effective (when a care provider has determined that you are not capable of making
a personal care decision (including health care)). When this happens your care provider will
look to your Personal Directive to see who should make the decision for you or to see if you
have provided instructions about the decision.
You should list the people you want to be told when you have been determined to be incapable
of making a personal care decision. You may want to list people who are close to you and who
will support you. This may include your family, spiritual advisor, Power of Attorney that you
have appointed, lawyer and others. It is helpful to list their contact information.
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There may be people who you do not want to be involved in your life when you become
incapable of making personal care decisions. You should list their names.
10. Compensation for Personal Care Services (optional)
If you want to name as your delegate the person who provides you with personal care
services for pay, then you must specifically authorize the details of your payment agreement
in your Personal Directive. It is advisable that you speak with a lawyer if you want to complete
this section.
11. Remuneration for Delegate (optional)
Generally, delegates can only be reimbursed for reasonable out-of-pocket costs associated
with being a delegate, but they cannot be paid for taking on the role of a delegate. However,
if you want to pay your delegate for acting as your delegate, then you must specifically set
out the details of this payment in your Personal Directive. It is advisable that you speak with
a lawyer if you want to complete this section.
12. Signatures (mandatory)
If your Personal Directive is not signed and witnessed properly, it will not be valid.
You must sign and date the Personal Directive in the presence of a witness. If you are
physically unable to sign the Personal Directive but you are mentally capable, you can
direct another person to sign for you in front of you and the witness. The person who
signs for you can’t be your delegate or their spouse.
Who witnesses your signature is important. The following persons may NOT witness the
signing of a Personal Directive:
•
A person you named as your delegate.
•
The spouse of your delegate. A spouse includes married, common law
(partners living together for 1 year or more) and registered domestic partners.
•
A person who signs the Personal Directive on your behalf.
•
The spouse of a person who signs the Personal Directive on behalf of the maker.
A spouse includes married, common law (partners living together for 1 year or more)
and registered domestic partners.
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Suggestions for after you complete your Personal Directive
•
Keep the original at home in a special place and tell trusted family and friends where it is.
•
Give a copy to:
– your delegate
– trusted family members and friends
– your physician and other people who will be providing care to you.
•
Take a copy with you:
– If you are traveling. Many provinces and U.S. states will honour
your wishes. Some will follow the rules in place in their province or U.S. state.
If you plan to travel you should check the procedure in that location.
– If you are admitted to a hospital or continuing care home.
•
List the people you have given copies of your Personal Directive to and keep this list
with your Personal Directive. If you change or cancel your Personal Directive,
let these people know.
Copies of my Personal Directive have been given to:
Name Relationship Contact Info
Note: This information is provided to help you understand the Personal Directives Act.
It is not legal advice or medical advice. Consult a professional if you need help to understand
your options and the implications of your choices.
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Information to think about when planning for future
personal care decisions
Some general information and descriptions of common health conditions and health
interventions that you may want to think about when planning for future care decisions
are provided below. You may want to discuss some of the health interventions with your
doctor before completing your Personal Directive.
Personal Care Terms
Clothing relates to decisions about what you want to wear. For example, you may want to
wear clothing that has religious or cultural significance, or you may want to look a certain way.
Comfort measures focus on care not cure. Some examples of comfort measures are: nursing care,
medication for managing symptoms including pain, oxygen for shortness of breath, fluids for
dehydration except by intravenous therapy, mouth care, positioning, warmth, emotional and
spiritual support, and other measures to relieve pain and suffering. Comfort measures do not
include treatment aimed at cure of the illness.
Continuing care homes are homes under the authority of the Departments of Health or
Community Services (for example, nursing homes and group homes).
Nutrition relates to the food or drink you may wish to have. You may want to receive a certain
type of diet (for example, vegetarian); you may want to receive food consistent with your cultural
or religious beliefs (for example, Kosher or Halal). Nutrition can become a health care issue
(for example, if you become diabetic).
Shelter is about where you live. You may wish to indicate your preferences about where you
would like to live, especially if you cannot be cared for at home. Do you prefer a specific
continuing care home? Do you prefer a geographical location?
Support services means services that help a person with daily activities such as
housekeeping, preparing meals, laundry, toileting, dressing, feeding, mobility and transportation
(for example, for grocery shopping and going to appointments).
Health Conditions
Stroke is a potentially life threatening event in which parts of the brain are deprived of blood
carrying oxygen. Strokes are commonly caused by either blockage of a blood vessel (usually in
the form of a clot) or by breaking of a blood vessel that results in bleeding in or around the brain.
The impact of a stroke on you physically and mentally can range from mild to severe. Stroke may
affect your ability to walk resulting in the need for a cane, or a wheelchair or confinement to
bed or a chair. Depending on the part of the brain affected, stroke may affect your ability to
communicate (e.g., speaking and/or understanding.) You may have the supports at home to
meet your needs or you may need to live in a continuing care home. How well you recover
from a stroke will depend on many factors.
Dementia is a term used to describe the symptoms of many illnesses that cause a loss of memory,
judgment, ability to think clearly, recognize people and communicate, as well as changes in
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behaviour and mood. These symptoms may be temporary and related to another condition,
or they may gradually get worse over time. Symptoms can range from mild to severe.
You might be forgetful at times but able to have meaningful conversations; you might sometimes
not recognize your family and friends, but usually be able to carry on conversations; you might
not recognize your family and friends and be unable to have a conversation. In the most
advanced stages of dementia you will need 24 hour care.
The most common form of dementia is Alzheimer’s Disease.
Permanent coma is a state of unconsciousness where there is no reasonable expectation of
regaining consciousness. You would need to be in bed and receive nourishment through a
feeding tube. You would need 24 hour care.
Health Interventions
Antibiotics are drugs that may be provided to treat an infection. For example, a person
with a terminal illness (such as bone cancer) may develop pneumonia. Left untreated,
it can lead to death. A person may choose to die of pneumonia rather than the terminal illness.
Blood transfusions are where blood is infused into your body through an intravenous line
(a needle in your vein).
Chemotherapy is a term used specifically to refer to drugs given to treat cancer.
Defibrillation is where the heart is given an electric shock. Sometimes this is used as part of
CPR to start the heart. Other times it is used to make an irregular heart beat become regular.
Intravenous therapy (IV) means that a needle is inserted into a vein, usually in your hand, arm
or foot. This needle is connected to a tube that can carry fluids and medications directly into
your blood stream.
Intubation is where a tube is inserted down your airway so that you can breathe. If you are
unable to breath on your own, intubation may result in the use of a ventilator or breathing
machine. Some people may want to be resuscitated, but may not want to be intubated.
A definition of ‘resuscitation’ is included below.
Kidney dialysis cleans the blood of toxins by machine (hemodialysis) or by fluid passed
through the abdomen (peritoneal dialysis). It is needed when the person’s kidneys are
not working.
Radiation is a concentrated x-ray beam directed at a certain spot (e.g., a cancerous growth).
Resuscitation (cardiopulmonary resuscitation [CPR]) is used to re-start the heart if it stops
beating. It includes chest compression, drugs, electric shocks and artificial breathing.
Television shows give the impression that CPR is highly successful, when in actual fact,
survival rates are about 0–20% depending on the person’s condition.
Surgery could include minor surgery (such as having wisdom teeth removed or feeding
tube inserted) or major surgery (such as having a gall bladder removed).
Tube feeding gives liquid nutrition through a tube into your body. A person who cannot
eat or drink needs a feeding tube to get nourishment. The tube is inserted into the stomach
either through the nose or a small hole cut into the abdomen.
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Personal Directive
I, _________________________________________________, make this Personal Directive.
Name of Maker
This Personal Directive is made pursuant to the Personal Directives Act and takes
effect if I am not capable of making a decision regarding my personal care.
I have placed my initials and my witness has placed his/her initials next to the
sections in this document that I want to be part of my Personal Directive.
1. Consultation when assessing capacity (optional)
The person making the assessment of my capacity is to consult with the following
person when making the assessment.
Name: _____________________________________________________________
Print Name, Title or Position of Individual
Address: _____________________________________________________________
Street Address
_____________________________________________________________
City/Town Province
Phone: _______________________________ Email: _________________________
Home Business
2. Revoking (Cancelling) Other Directions (optional)
I revoke (cancel) all previous instructions, personal directives, and authorizations,
including those made pursuant to the Medical Consent Act.
OR
I revoke (cancel) only the following instructions, personal directives or authorizations:
Date: _________________________________
Description:
_____________________________________________________________________
_____________________________________________________________________
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
Rev. 03/10 Page 1 of 7
3. Authorization to Act as Delegate (optional)
I authorize the following person to act as my delegate to make personal care decisions
on my behalf for all personal matters, of a non-financial nature, that relate to me.
Name: _____________________________________________________________
Print Name of Delegate
Address: _____________________________________________________________
Street Address
_____________________________________________________________
City/Town Province
Phone: _______________________________ Email: _________________________
Home Business
If my delegate is unable, unwilling or unavailable to make a personal care decision,
I authorize the following person to act as my alternate delegate.
Name: _____________________________________________________________
Print Name of Alternate Delegate
Address: ____________________________________________________________
Street Address
_____________________________________________________________
City/Town Province
Phone: _______________________________ Email: _________________________
Home Business
OR
I want to authorize more than one delegate to make different personal care
decisions on my behalf. I authorize the following individuals to act as my delegates
and alternate delegates (if the delegate is unable, unwilling or unavailable to make
a personal care decision) to make personal care decisions on my behalf for all the
following personal care matters, of a non-financial nature, that relate to me:
health care __________________________ __________________________
Name of Delegate and contact information Name of Alternate Delegate
and contact information
home care services __________________________ __________________________
Name of Delegate and contact information Name of Alternate Delegate
and contact information
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
Rev. 03/10 Page 2 of 7
accommodation, __________________________ __________________________
including placement N
ame of Delegate and contact information Name of Alternate Delegate
in a continuing-care and contact information
home
with whom I may __________________________ __________________________
live and associate Name of Delegate and contact information Name of Alternate Delegate
and contact information
participation in __________________________ __________________________
social activities Name of Delegate and contact information Name of Alternate Delegate
and contact information
participation in __________________________ __________________________
educational activities Name of Delegate and contact information Name of Alternate Delegate
and contact information
participation in __________________________ __________________________
employment activities Name of Delegate and contact information Name of Alternate Delegate
and contact information
other personal care __________________________ __________________________
matters as follows: Name of Delegate and contact information Name of Alternate Delegate
and contact information
________________________________________________________________________
4. No Delegate Authorized (optional)
I DO NOT wish to authorize a delegate, but have provided instructions in section 5
for persons who intend to provide personal care services to me.
5. Specific Instructions (optional)
I instruct my delegate(s) to carry out the following specific instructions when
making decisions about my personal care:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
additional page attached? q Yes q No
_____ _____
Witness’ Your
Initials Initials
Rev. 03/10 Page 3 of 7
If I have not designated a delegate(s), or if my delegate(s) and alternate
delegate(s) are unable, unwilling or unavailable to make a personal care
decision, I instruct all persons who intend to provide personal care services
to me to follow the following instructions that are relevant to the decisions
to be made:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
additional page attached? q Yes q No
6. Other Information (optional)
I provide the following information to help my delegate(s) or statutory
decision-maker understand my values, beliefs and wishes when making
decisions about my personal care:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
additional page attached? q Yes q No
7. Instructions about Statutory Decision-makers (optional)
I DO NOT wish to authorize a delegate and am comfortable with a relative
authorized under section 14 of the Personal Directives Act making decisions
on my behalf about health care, home care and placement in a continuing
care home, except I DO NOT want the following relative(s) making decisions
on my behalf:
___________________________________________________________________
Name Relationship
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
Rev. 03/10 Page 4 of 7
8. Consultation when Delegate Making Decisions (optional)
My delegate(s) is to consult with the following person(s) when making
decisions about my personal care.
Name: ____________________________________________________________
Print Name of Delegate
Address: ___________________________________________________________
Street Address
____________________________________________________________
City/Town Province
Phone: _______________________________ Email: ______________________
Home Business
9. Notification (optional)
If it is determined that I lack capacity to make a personal care decision,
I instruct the person making the determination to notify me, the delegate(s)
I have authorized in this Personal Directive, if any, and the following people:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
If is determined that I lack capacity to make a personal care decision,
the following people are not to be notified of the determination:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
10. Compensation for Personal Care Services (optional)
My delegate, __________________________________________, is authorized to
Name of Delegate
receive compensation for providing me with personal care services on the following terms:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
_____ _____
Witness’ Your
Initials Initials
Rev. 03/10 Page 5 of 7
11. Remuneration for Delegate (optional)
My delegate, __________________________________________, is authorized
Name of Delegate
to receive remuneration for exercising his/her authority under this personal directive
on the following terms:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
12. Signatures (mandatory)
Signed by me in the presence of my witness at ______________________, in the Province of
Location
Nova Scotia, this ______________ day of ___________________________, ___________.
Day Month Year
_________________________________
Printed Name of Witness
_________________________________ _________________________________
Printed Name of Maker Relationship to Maker
_________________________________ _________________________________
Signature of Maker in the presence of the Witness Signature of Witness in the presence of the Maker
_________________________________ _________________________________
Street Address Street Address
_________________________________ _________________________________
City/Town City/Town
_________________________________ _________________________________
Province Province
_________________________________ _________________________________
Home Phone Number Business Phone Number Home Phone Number Business Phone Number
_________________________________ _________________________________
Email Email
_____ _____
Witness’ Your
Initials Initials
Rev. 03/10 Page 6 of 7
OR (where Maker physically unable to sign)
Signed on behalf of the Maker, ______________________________, in the presence of the
Name of Maker
Maker and in the presence of the witness at _______________________, in the Province of
Location
Nova Scotia, this ______________ day of ___________________________, ___________.
Day Month Year
_________________________________ _________________________________
Print Name of Person signing on behalf of Maker Print Name of Witness
_________________________________
Relationship to Maker
_________________________________ _________________________________
Signature of Person signing on behalf of Maker Signature of Witness in the presence of the Maker
in the presence of the Maker
_________________________________ _________________________________
Street Address Street Address
_________________________________ _________________________________
City/Town City/Town
_________________________________ _________________________________
Province Province
_________________________________ _________________________________
Home Phone Number Business Phone Number Home Phone Number Business Phone Number
_________________________________ _________________________________
Email Email
Rev. 03/10 Page 7 of 7
Notes
