PRINCE EDWARD ISLAND
of , Prince Edward Island.
1. Who will be my health-care proxy and alternate?
a) I appoint of
, Prince Edward Island, as my proxy to make personal and health-care decisions pursuant to the Consent to Treatment and Health-Care Directives Act.
b) If he or she is unwilling or unable to act then I appoint
of , Prince Edward Island, 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 completed by
of 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 health-care 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 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 proxy’s knowledge of my wishes, values, and beliefs.
d) If my proxy 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 , Prince Edward Island, this
day of , 20 .
(Signature of maker)
(Print name of maker)
(Signature of witness)
(Print name of witness)
AGREEMENT TO ACT AS SUBSTITUTE DECISION MAKER
I, (print name of substitute
decision maker), have been informed that
(print name of incapable person) has been found incapable of consenting to the proposed treatment
1. My relationship to the incapable person is (see priority order below) and —
a) I am at least sixteen years old;
b) I am capable of giving consent on behalf of the above-named person;
c) I have knowledge of the circumstances of, and have been in contact with, the person; and
d) I am a substitute decision maker pursuant to section 11 of the Consent to Treatment and Health Care Directives Act.
2. Where the conditions stated in subsection 11(6) of the Act apply, I am the public official empowered with the duty of public guardianship pursuant to subsection 11(6) of the Act.
I hereby certify that I meet —
a) the requirements of section 1 above; or
b) where subsection 11(6) of the Act applies, the requirements of section 2 above and agree to serve as substitute decision maker for the above-named person.
My mailing address, telephone and fax number are:
(Mailing address) (Date)
(Phone number) (Signature of substitute decision maker)
If agreement to act as a substitute decision maker has been obtained by telephone, the conversation must be witnessed by a third party who will sign below:
(Signature of third party witness)
Form C — Continued
PRIORITY ORDER OF SUBSTITUTE DECISION MAKERS
NOTE: The health practitioner must make reasonable inquiry regarding the existence of a substitute decision maker and determine who can make a decision.
1. Proxy — appointed by the individual when capable
2. Guardian if having authority to give or refuse consent to treatment
3. Spouse means a person —
a) to whom the person is married, or
b) with whom this person is living in a conjugal relationship outside marriage, if the two persons
i. have cohabited for at least three years,
ii. are in a relationship of some permanence and are together the parents of a child, or
iii. have together entered into a cohabitation agreement under section 52 of the Family Law Act, R.S.P.E.I. 1988, Cap.F-2
4. Son, daughter, or parent; or a person who has assumed parental authority and who is lawfully entitled to give or refuse consent to treatment on the person’s behalf
5. Brother or sister
6. Trusted friend
7. Other relative
8. Public guardian — If no one listed above is available,* capable, and willing to assume responsibility for making a decision, or if there is disagreement among persons of the same class (subsection 11(6))
*Available — Subsection 11(7) of the Act states a person is available if it is possible for the health practitioner, within a time that is reasonable in the circumstances, to communicate with the person and obtain a decision.