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Care Directive Form for Newfoundland and Labrador

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NEWFOUNDLAND AND LABRADOR
ADVANCE HEALTH-CARE DIRECTIVE

Made by          

of                           , Newfoundland and Labrador.

 

1.         Who will be my substitute decision maker and alternate?

a)   I appoint           of

        , Newfoundland and Labrador, as my substitute decision maker pursuant to the Advance Health-Care Directives Act. 

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

of         , Newfoundland and Labrador, as my substitute decision maker in his or her place.

2.         When will this appointment 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 completed by          of

        , Newfoundland and Labrador, 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 the 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 directive will have no effect and my instructions must be followed.

b)   If I am unable to communicate, my substitute decision maker is to follow my instructions below.

c)   If I have not left instructions on the issue at hand, then my substitute 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 substitute 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 substitute decision maker.

 

 

Signed at                           , Newfoundland and Labrador, this                  

day of                           , 20                          .

 

                       

(Signature of maker)

                       

(Print name of maker)

                       

(Signature of witness)

                       

(Print name of witness)