of , Manitoba.
1. Who will be my health-care proxy and alternate?
a) I appoint of
________________________________________________, Manitoba, as my proxy under the Manitoba Health-Care Directives Act.
b) If he or she is unwilling or unable to act, then I appoint
Manitoba, as my proxy in his or her place.
2. When does 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
, Manitoba, 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 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 are to 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 agent is to make for me the decisions I would have made for myself, based on my agent’s 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 , Manitoba, this
day of , 20 .
(Signature of maker)
(Print name of maker)
(Signature of witness)
(Print name of witness)