Sample Directive: Appointing an Agent and Stating Instructions

Personal Directive

I, _______________________________________,of ___________________, Alberta, do hereby:

Appoint ______________________________________, as my Agent; pursuant to the Personal Directives Act of Alberta. If (s)he predeceases me or is unavailable or unwilling to act, then I appoint ________________________________, to be my Alternate Agent. Any Agent appointed by me shall have full authority to interpret all personal and medical decisions, and the instructions below, even if they have no bearing upon the actual situation, should I be unable to make these decisions for myself.

Primary Agent

Agent's name: ______________________

Agent's address:

____________________________________

____________________________________

____________________________________

Home Number: ______________________

Work Number: _______________________

 Alternate Agent

Agent's name: ______________________

Agent's address:

___________________________________

___________________________________

___________________________________

Home Number: ______________________

Work Number: ______________________

If at such a time the situation arises in which there is no reasonable expectation of my recovery from severe physical or mental disability to a state of meaningful interaction with loved ones, family and friends, I would like the following directions to be followed:

  1. Measures of artificial life-support, in the above stated situation, that I refuse are:
    • Cardiopulmonary resuscitation and admittance into an intensive care unit.
    • Mechanical respiration when I cannot breathe by myself.
    • Prolonged gastric tube or intravenous feeding when I am indefinitely unable to eat through my mouth.
    • Antibiotic medication to treat or prevent infection.
    • Other: _______________________________________________

  2. I request to live my last days at home rather than a hospital, if my family agrees.

  3. If any of my tissues or organs are healthy and useful for other people I give permission for all such donation, or as specified during my life: _______________________________________

  4. I do wish to have medication mercifully administered to me in order to stop suffering even though this may shorten my remaining life.

Dated at ___________________ in the Province of Alberta, this ________ day of _________________, 20_____.

 ____________________________

Witness' Signature

 _____________________________

Maker's Signature


The appearance of this sample personal directive does not imply endorsement by the Provincial Health Ethics Network; it is provided for information purposes only. PHEN assumes no liability for any loss or damage suffered by any person by reason of their reliance on the information contained herein.