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CAUTION!!! This next section is not a tool to help you obtain medical treatment. It is a directive that gives health care providers instructions to WITHHOLD medical treatment. We have included it in this workbook so you can use it if YOU DO NOT WANT MEDICAL TREATMENT IN CRITICAL HEALTH CARE CIRCUMSTANCES.

8. Advance Health Care Directive - Your Copy

Manitoba Health Care Directive (Please type or print legibly)

This is the Health Care Directive of

Name ____________________________________
Address __________________________________
City _____________________________________
Province__________ Postal Code______________
Tel. (____)__________________________________
Signature _________________________________

PART 1 – Designation of a Health Care Proxy

You may name one or more persons who will have the power to make decisions concerning your medical treatment when you lack the ability to make those decisions yourself. If you do not wish to name a proxy, you may skip this part.

I hereby designate the following person(s) as my Health Care Proxy:

Name of Proxy 1____________________________
Address _________________________________
City ______________________________________
Province___________ Postal Code_____________
Tel. (____)___________________________________
Name of Proxy 2 (Optional)___________________
Address___________________________________
City ______________________________________
Province____________ Postal Code_____________
Tel. (____)___________________________________

If I have named more than one proxy, I wish them to act: consecutively ____ jointly___.

(Initial or check your choice. If you do not, Proxy 2 will be deemed to act only if Proxy 1 cannot or will not act.)

I place no restriction on the ability of my Health Care Proxy to make medical decisions on my behalf when I lack the capacity to do so for myself, except as follows:

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

PART 2 – Treatment Instructions

In this part, you may set out your instructions concerning medical treatment which you do or do not wish to receive and the circumstances in which you do or do not wish to receive that treatment. REMEMBER – your instructions can only be carried out if they are set out clearly and precisely. If you do not wish to express any treatment instructions, you may skip this part.

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

PART 3 – Signature and Date

In order to be valid this Health Care Directive must be dated and signed by you. No witness is required.

Signature __________________________________________
Date ______________________________________________

If you are unable to sign yourself, you may have someone sign on your behalf. In that case, the substitute must sign in your presence and in the presence of a witness. The proxy or the proxy’s spouse cannot be the substitute signer or witness.

Name of substitute____________________________________________
Address____________________________________________________
Signature___________________________________________________
Date______________________________________________________________________
Name of witness_________________________________________________________
Address __________________________________________________________________
Signature_________________________________________________________________
Date ______________________________________________________________________


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