AUTHORITY REGARDING MEDICAL TREATMENT
of , Nova Scotia.
1. Who will be my health-care decision maker and alternate?
a) I appoint of
, Nova Scotia, as my health-care decision maker pursuant to the Medical Consent Act of Nova Scotia.
b) If he or she is unwilling or unable to act, then I appoint of
, Nova Scotia, as my health-care decision maker in his or her place.
2. When will this authority come into effect?
a) This authority will only be in effect if, and only as long as, I am unable to make or communicate my own directions about and consent to medical treatment due to lack of capacity.
b) A declaration by of
, Nova Scotia, will be sufficient proof that I lack the capacity to give directions about or consent to medical treatment.
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 decision maker make 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 authority will have no effect and my instructions must be followed.
b) If I am unable to communicate, my decision maker is to follow my instructions below.
c) If I have not left instructions on the issue at hand, then my decision maker is to make for me the decisions I would have made for myself, based on his or her knowledge of my wishes, values, and beliefs.
d) If my decision maker 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 decision maker.
Signed at , Nova Scotia, this
day of , 20 .
(Signature of maker)
(Print name of maker)
(Signature of witness)
(Print name of witness)