PERSONAL DIRECTIVE
of ____________________

I, ____________________ (the "Director"), of ______________________________________________________________, phone: __________, being of sound mind and at least 19 years of age, make this Personal Directive fully understanding the consequences of my action in doing so. I intend this Personal Directive to be read by my health care providers, family and friends as a true reflection of my wishes and instructions should I lack Capacity and be unable to communicate such wishes and instructions.

1. Definitions
   
1. As used in this document:
   
   1. "Act" means the Northwest Territories Personal Directives Act.
      
   2. "Capacity" is determined by two persons, each of whom is either a medical practitioner or a psychologist. The two persons jointly or separately assess the director's condition and make a written and dated declaration that the director lacks capacity.
      
2. Revoke Previous Personal Directive
   
2. I revoke any previous Personal Directive made by me.
   
3. Designation of Agent
   
3. I do not wish to designate an Agent, but provide the following information and instructions to be followed by a service provider who intends to provide personal services for me.
   
4. Notwithstanding the previous clause, I give no one (including my Agent) any authority to disregard or override my instructions provided in this Personal Directive. Family members, relatives, friends may disagree with me, but any such disagreement does not diminish the strength or substance of my instructions.
   
5. Treatment Directions and End-Of-Life Decisions
   
5. I direct that my health care providers and others involved in my care provide, withhold or withdraw treatment in accordance with my directions below:
   
   1. If I have an incurable and irreversible terminal condition that will result in my death within a relatively short time, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   2. If I am diagnosed as persistently unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
   3. If I am diagnosed as being severely and permanently mentally impaired, I direct that:
      
      1. I be kept on any artificial life support as long as possible within the limits of generally accepted health care standards;
         
      2. I receive tube feeding if necessary, even if such feeding would have the effect of prolonging my life;
         
      3. Cardiopulmonary resuscitation be performed if, in the opinion of my doctor, it is necessary; and
         
      4. Should I develop another separate condition that threatens my life, such other illness be given active treatment if, in the opinion of my doctor, such treatment is indicated.
         
6. Revocation
   
6. The authority granted in this Personal Directive may be revoked as and where permitted by law.
   
7. I understand that, as long as I have Capacity, I may revoke this Personal Directive at any time.
   
8. Statement of Values and Beliefs
   
8. ________________________________________________________________________________________________________________________.
   
9. General
   
9. A copy of this Personal Directive has the same effect as the original.
   
10. If any part or parts of this Personal Directive is found to be invalid or illegal under applicable law by a court of competent jurisdiction, the invalidity or illegality of that part or parts will not in any way affect the remaining parts and this document will be construed as though the invalid or illegal part or parts had never been included in this Personal Directive. But if the intent of this Personal Directive would be substantially changed by such construction, then it shall not be so construed.
    
11. This Personal Directive is intended to be governed by the laws of the Northwest Territories.
    

Signature

Signed by me under hand and seal in the presence of my witness in the Northwest Territories, this ________ day of ________________, ________.

Record of Copies
Record of people and institutions to whom I have given a copy of this Personal Directive:

General comments regarding your Personal Directive

1. Read the entire document before you sign in the space provided. Make sure it says what you want it to say.
   
2. Do not leave any blank lines above your signature to be filled in after signing. Make sure there are no blank lines before you sign.
   
3. Each page should be numbered. (e.g. 1 of 3, 2 of 3, etc.)
   
4. You and your witness should initial all the pages.
   

Signing requirements for your Northwest Territories Personal Directive

The Personal Directive must contain:
               - the director's full name and signature;
               - the full name and signature of any person designated as an agent;
               - an agent declaration stating that the person is eligible to be an agent and that the person is aware of and accepts the instructions in the directive and the duties of an agent under the Act;
               - the name and signature of a witness to the signature of the director. The witness and director must sign in the presence of each other; and
               - the name and signature of a witness to the signature of each agent. The witness and agent will sign in the presence of each other.

               Signing on Behalf of the Director:
               - If the director is unable to read or sign a personal directive, the directive must be signed at the director's request by another person on behalf of the director and that substitute signer must sign the directive in the presence of both the director and a witness or the director must acknowledge the signature in the presence of a witness and the witness must sign the directive in the presence of the director.
               - An agent or his or her spouse may not sign a personal directive on behalf of the director.

               Witnesses:
               - The following persons may not act as witness: an agent, the spouse of an agent, the spouse of the director, a person who signs the directive on behalf of the director, or the spouse of a person who signs on behalf of the director.

Limitations to the authority of your Agent

Unless authorized in the Personal Directive, a substitute decision maker cannot consent to:
               - sterilization that is not medically necessary for the protection of the health of the director;
               - the removal of tissue from the director's living body for transplantation to another person or for the purpose of medical education or medical research;
               - psychosurgery;
               - participation by the director in medical research or experimental activities, unless there is a reasonable likelihood of benefit to the director; or
               - any other health care prevented by regulation, legislation or court order.