Personal Care Power of Attorney

POWER OF ATTORNEY FOR PERSONAL CARE

THIS POWER OF ATTORNEY FOR PERSONAL CARE is made by ______, residing in the City of ______, in the Province of ______.

REVOCATION

I. All previous Powers of Attorney for Personal Care or any earlier power of attorney affecting my personal care that I have granted are hereby revoked. I reserve the right to create additional Powers of Attorney for Personal Care in the future.

APPOINTMENT

II. I HEREBY APPOINT:

as my attorney for personal care under the Substitute Decisions Act, 1992 and I grant my attorney for personal care the authority to make decisions regarding my personal care, encompassing health care, nutrition, shelter, clothing, hygiene, and safety, in accordance with the Substitute Decisions Act and subject to any conditions, restrictions, specific directions, or special provisions set out in this document.

I wish my attorney(s) to hold authority to act: ______

SUBSTITUTE APPOINTMENT

III. If my attorney is unable or unwilling to serve due to death, removal by court order, incapacity, or resignation, or is unavailable when a decision regarding my personal care or treatment governed by the Health Care Consent Act is required, I SUBSTITUTE AND APPOINT:

to serve as my attorney for personal care, replacing and holding all powers granted to the attorney named in paragraph (II) above. The term 'my attorney' as used throughout this document shall, where the context allows, refer to whichever one or more persons are appropriate given the appointments made in paragraphs II and III above.

CONDITIONS AND RESTRICTIONS

IV. I acknowledge that death is inevitable. If, as my life draws to a close, I can no longer make decisions about my future, can no longer communicate, am unable to care for myself, have no reasonable prospect of recovering from severe physical or mental disability or incapacity, find myself in circumstances that prevent rational existence, or am suffering from an irreversible injury, disease, illness, or condition, then I direct my attorney to honour the following wishes:

(a) Where artificial life-sustaining measures would serve only to delay the moment of my death, let this document express my considered thoughts, intentions, wishes, and directions - that I ______. I sign this document freely and voluntarily, while of sound mind and emotionally capable of making such decisions.

(b) I believe in the principle of dying with dignity. Should any of the circumstances described in the preceding paragraphs arise, I direct that I be ______.

(c) The following are my specific requests:

(i) I request that ______.

(ii) If it will not cause undue hardship to my family, I wish to die at ______ rather than in an institution.

(iii) Should I be under the care of a physician whose moral, ethical, or religious convictions conflict with the wishes expressed in this document, I direct my attorney to request that physician to withdraw from my care and to recommend another physician who will respect my views on the prolongation of life. My attorney is also empowered to arrange my transfer to another hospital if necessary to carry out the directions in this document.

(iv) I hereby authorize and direct my attorney to pay from my assets any and all costs and expenses, including legal fees and court costs, that they consider necessary to ensure my directions as stated herein are carried out.

(v) No person involved in the creation or execution of this Power of Attorney for Personal Care, whether a health care provider, hospital administrator, spouse, relative, friend, or any other individual, shall be held liable in any way, legally, professionally, or morally, for any consequences resulting from the implementation of my wishes.

(vi) My wishes regarding living arrangements and accommodation are: ______.

(vii) Persons I ask my attorney to consult (if any):

(viii) Conditions and restrictions that apply to my attorney (if any):

(ix) Any dispute between my attorneys shall be resolved as follows: ______.

CONSENT TO TREATMENT

V. I authorize my attorney to give or withhold consent on my behalf to treatment to which the Health Care Consent Act, 1996, applies.

ASSESSMENT OF CAPACITY

VI. If my capacity for personal care becomes an issue and a capacity assessment is needed, my physician at the time shall conduct the assessment; if that physician is unable or unwilling to do so, then any other physician or authorized capacity assessor chosen by my attorney shall perform such assessment.

COMPENSATION

VII. I declare that my attorney shall not be entitled to compensation from my assets for serving as my attorney and carrying out the duties and obligations required under this document. However, it is my wish that my assets be used to reimburse my attorney for any out-of-pocket expenses they incur in performing their duties and obligations hereunder.

SIGNED at the City of __________________, Province of __________________, this ____ day of __________ 20____, in the presence of the Witnesses named below. Neither witness is an attorney named in this document, a spouse or partner of the person granting this power of attorney, a child of the grantor or a person whom the grantor has shown a settled intention to treat as a child, nor a person whose property is under guardianship or who has a guardian of the person, nor a person under 18 years of age.

__________________________

Grantor: ______

__________________________ ___________________________

Name (1st Witness): Name (2nd Witness):

Address: Address

Occupation: Occupation: