Free Care Directive Form for Saskatchewan

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SASKATCHEWAN
ADVANCE HEALTH-CARE DIRECTIVE

Made by          

of                           , Saskatchewan.

 

1.         Who will be my health-care proxy and alternate?

a)   I appoint          of

        , Saskatchewan, as my proxy to make personal and health-care decisions pursuant to the Health-Care Directives and Substitute Health-Care Decision Makers Act.

b)      If he or she is unwilling or unable to act, then I appoint        

        of          ,

Saskatchewan, as my proxy in his or her place.

 

2.         When will this directive come into effect?

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

b)   A declaration by          of

        , Saskatchewan, will be sufficient proof that I lack the capacity to make or communicate my own health- or personal-care decisions.

c)   If he or she is unable or unwilling to make a determination about my capacity, or cannot be reached after every reasonable effort has been made, then a written declaration signed by two physicians who are familiar with my circumstances will suffice.

 

3.         How will my proxy make health-care decisions for me?

a)   If I am able to communicate in any way, including by gestures as well as by speaking or writing, then this directive will have no effect and my instructions must be followed.

b)   If I am unable to communicate, my proxy is to follow my instructions below.

c)   If I have not left instructions on the issue at hand, then my proxy is to make for me the decisions I would have made for myself, based on my proxys knowledge of my wishes, values, and beliefs.

d)   If my agent does not know what my wishes, beliefs, and values are with respect to a particular issue, then he or she is to make the decision that he or she believes is in my best interests under the circumstances.

 


4.         My instructions about end-of-life treatments

(Insert clause chosen from Sample 1.)

 

 

5.         My signature

I confirm that I understand this document and the power it gives to my proxy.

 

 

Signed at                           , Saskatchewan, this                    day of

                          , 20                          .

 

                       

(Signature of maker)

                       

(Print name of maker)

                       

(Name of witness)

                       

(Signature of witness)