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11/5/2019

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Personal Directive...

Congratulations on completing your personal directive. Your family and future caregivers will be grateful that you have taken the time to think about and record these important decisions.

Your personal directive is attached to this email. All you have to do is print copies and sign them in front of one witness and have your witness sign them as well. If you are unable to sign your directive, someone you trust can sign on your behalf (they cannot be your delegate or the spouse of your delegate and must sign it in the presence of you and your witness).

Print enough copies for the people who need to know about your directive and one for yourself:

trusted family members
your delegates if you named any
your doctor or nurse practitioner

Raw Data Registration Structure Registration Form Text

Registration

Invalid Input Naming someone to make decisions for you�your delegateYou may use your personal directive to name someone to make personal care decisions for you when you cannot do it yourself. That person is called a delegate. Your delegate does not have to be a relative. They must be at least 19 years old, unless they are your spouse. Your spouse can be your delegate even if they are under 19. Pick one of the following(*)

Name (full)

Home address

City

State

Page 1 of 6 My Personal Directive Please complete all required fields! A personal directive is one of the greatest gifts you can give yourself and those who care about you. You must make your personal directive while you can still make decisions for yourself. You might not be able to make health care decisions for yourself at some time in the future. A personal directive can help to make sure that you get the care you want. It can help the people who care about you by letting them know what kinds

I want to name a delegate.

I want to name more than one delegate.

Invalid Input You may also name an alternate delegate who can make decisions about your personal care if your delegate cannot, will not, or is not available. You may also name more alternate delegates to make decisions in case your first alternate cannot. An alternate delegate must be 19 unless they are your spouse. Pick one of the following(*)

I wish to name an alternate delegate or delegates.

Invalid Input Next > Giving delegates power to choose a replacement delegate You may allow your delegates to give their responsibilities for your personal care decisions to someone else. This is called sub-delegating their authority to another person. That person will have all the authority your delegates give them. Your delegates may sub-delegate only if you say in your personal directive that they may do so. Pick one of the following.(*)

My delegates may sub-delegate their decision-making authority.

Invalid Input Allowing a former spouse to be a delegate after divorce If you name your spouse to act as a delegate or alternate delegate and then they stop being your spouse, your former spouse may still act as your delegate only if you say so in your personal directive. Otherwise, since your former spouse is no longer your spouse, that part of your personal directive is no longer valid. Pick one of the following.(*)

I named my spouse to act as a delegate or alternate delegate.

I did not name my spouse to act as a delegate or alternate delegate. Invalid Input If my spouse is no longer my spouse after I complete this personal directive.

I wish my spouse to continue to act as a delegate.

Invalid Input < PrevNext > Instructions and wishes about personal care You may give instructions or make statements about your wishes for personal care. If you do, your delegates (if you have any), or statutory decision makers, or your health care providers must follow them. You can choose to not leave any instructions or wishes about your personal care decisions. If you do this, anyone who makes personal care decisions for you must base them on what they know about your values

I have instructions or wishes about my personal care decisions.

Invalid Input Values and beliefs relevant to personal care If you do not give clear instructions or a clear description of your wishes above, your delegate will have to make decisions about your care based on what they think you would want based on what they know about your values and beliefs. If you don�t name a delegate or leave clear instructions or wishes about your care, a statutory decision maker must act according to what they think you would want. You can choose to not write down your values and

I want to give information about my values and beliefs.

Invalid Input Who the delegate must talk to when making personal care decisions You can say in your personal directive that your delegate must talk with other people when making personal care decisions for you. You can do this by naming the people your delegate should talk with. Instructing your delegate to talk with other people when making care decisions for you can help in two ways. First, people who knew you when you could make decisions may know about your instructions, values, beliefs, and wish

I wish to give instructions about who my delegate must talk with when making personal care decisions.

Invalid Input < PrevNext > Consultation when assessing capacity Your personal directive takes effect when you can no longer make personal care decisions for yourself. This is called losing capacity. To decide if you have lost capacity, a health care professional will assess (or test) your ability to make decisions. This might include talking with people who know you well. You may name who you want the health care provider to talk to when they assess your capacity. The person or

I want the person who assesses my capacity to talk to the people I name.

Invalid Input Telling people about your loss of capacity You may give instructions about who must be told when you lose capacity to make personal care decisions.You can also say who must not be told. Pick one of the following(*)

I wish to give instructions about who must and must not be told if I lose capacity.

Invalid Input < PrevNext > The questions on this page are about paying and reimbursing delegates. As you have not chosen a delegate to make decisions for you, please just click Next. Paying delegates to care for you You might name someone who is not your spouse or relative to be your delegate. If you do and you wish to pay them for their services, you must say this in your personal directive. Pick one of the following

My delegates are my spouse or relatives.

I have named a delegate who is not my spouse or relative, and I wish them to be paid for their personal care services.

Invalid Input Paying delegates to make decisions If you want to pay your delegates for making decisions under your personal directive, you must say that they can be paid. Nova Scotia law says that delegates cannot be paid to make decisions under your personal directive, unless you say in your personal directive that you want to pay them. Pick one of the following

My delegate is my spouse or a relative.

I want one or more delegates to be paid for making decisions under this personal care directive.

Invalid Input Repaying your delegates� costs If you want your delegate to be repaid for any costs they must pay while acting as your delegate, you must say that. Even if you do not say so in your personal directive, your delegates can be repaid for reasonable costs while acting as your delegates. However, the law is not completely clear. To be sure that your delegates can be repaid for their costs, you should fill out this section. Pick one of the following

I want my delegates to be repaid for costs while acting as my delegates.

Invalid Input < PrevNext > Review and Finalize Review the personal directive below the submit button. You can change any of your answers by using the Prev/Next buttons. If you are finished making your personal directive, click Submit to create a page you can sign. After you click Submit, a page will appear with a link so you can download a pdf of your responses with a signing page. If you give your email address below, we will ALSO email a copy of the pdf. Will you be able to

Yes (will create a document you can sign)

Data Name	Data Type	Options
Invalid Input Naming someone to make decisions for you�your delegateYou may use your personal directive to name someone to make personal care decisions for you when you cannot do it yourself. That person is called a delegate. Your delegate does not have to be a relative. They must be at least 19 years old, unless they are your spouse. Your spouse can be your delegate even if they are under 19. Pick one of the following(*)	Text Box
Name (full)	Text Box
Email	Text Box
Home address	Text Box
City	Text Box
State	Text Box
	checklist	Page 1 of 6 My Personal Directive Please complete all required fields! A personal directive is one of the greatest gifts you can give yourself and those who care about you. You must make your personal directive while you can still make decisions for yourself. You might not be able to make health care decisions for yourself at some time in the future. A personal directive can help to make sure that you get the care you want. It can help the people who care about you by letting them know what kinds
	option	Invalid Input Naming someone to make decisions for you�your delegateYou may use your personal directive to name someone to make personal care decisions for you when you cannot do it yourself. That person is called a delegate. Your delegate does not have to be a relative. They must be at least 19 years old, unless they are your spouse. Your spouse can be your delegate even if they are under 19. Pick one of the following(*)
	option	I want to name a delegate.
	option	I want to name more than one delegate.
	option	Invalid Input You may also name an alternate delegate who can make decisions about your personal care if your delegate cannot, will not, or is not available. You may also name more alternate delegates to make decisions in case your first alternate cannot. An alternate delegate must be 19 unless they are your spouse. Pick one of the following(*)
	option	I wish to name an alternate delegate or delegates.
	option	Invalid Input Next > Giving delegates power to choose a replacement delegate You may allow your delegates to give their responsibilities for your personal care decisions to someone else. This is called sub-delegating their authority to another person. That person will have all the authority your delegates give them. Your delegates may sub-delegate only if you say in your personal directive that they may do so. Pick one of the following.(*)
	option	My delegates may sub-delegate their decision-making authority.
	option	Invalid Input Allowing a former spouse to be a delegate after divorce If you name your spouse to act as a delegate or alternate delegate and then they stop being your spouse, your former spouse may still act as your delegate only if you say so in your personal directive. Otherwise, since your former spouse is no longer your spouse, that part of your personal directive is no longer valid. Pick one of the following.(*)
	option	I named my spouse to act as a delegate or alternate delegate.
	option	I did not name my spouse to act as a delegate or alternate delegate. Invalid Input If my spouse is no longer my spouse after I complete this personal directive.
	option	I wish my spouse to continue to act as a delegate.
	option	Invalid Input < PrevNext > Instructions and wishes about personal care You may give instructions or make statements about your wishes for personal care. If you do, your delegates (if you have any), or statutory decision makers, or your health care providers must follow them. You can choose to not leave any instructions or wishes about your personal care decisions. If you do this, anyone who makes personal care decisions for you must base them on what they know about your values
	option	I have instructions or wishes about my personal care decisions.
	option	Invalid Input Values and beliefs relevant to personal care If you do not give clear instructions or a clear description of your wishes above, your delegate will have to make decisions about your care based on what they think you would want based on what they know about your values and beliefs. If you don�t name a delegate or leave clear instructions or wishes about your care, a statutory decision maker must act according to what they think you would want. You can choose to not write down your values and
	option	I want to give information about my values and beliefs.
	option	Invalid Input Who the delegate must talk to when making personal care decisions You can say in your personal directive that your delegate must talk with other people when making personal care decisions for you. You can do this by naming the people your delegate should talk with. Instructing your delegate to talk with other people when making care decisions for you can help in two ways. First, people who knew you when you could make decisions may know about your instructions, values, beliefs, and wish
	option	I wish to give instructions about who my delegate must talk with when making personal care decisions.
	option	Invalid Input < PrevNext > Consultation when assessing capacity Your personal directive takes effect when you can no longer make personal care decisions for yourself. This is called losing capacity. To decide if you have lost capacity, a health care professional will assess (or test) your ability to make decisions. This might include talking with people who know you well. You may name who you want the health care provider to talk to when they assess your capacity. The person or
	option	I want the person who assesses my capacity to talk to the people I name.
	option	Invalid Input Telling people about your loss of capacity You may give instructions about who must be told when you lose capacity to make personal care decisions.You can also say who must not be told. Pick one of the following(*)
	option	I wish to give instructions about who must and must not be told if I lose capacity.
	option	Invalid Input < PrevNext > The questions on this page are about paying and reimbursing delegates. As you have not chosen a delegate to make decisions for you, please just click Next. Paying delegates to care for you You might name someone who is not your spouse or relative to be your delegate. If you do and you wish to pay them for their services, you must say this in your personal directive. Pick one of the following
	option	My delegates are my spouse or relatives.
	option	I have named a delegate who is not my spouse or relative, and I wish them to be paid for their personal care services.
	option	Invalid Input Paying delegates to make decisions If you want to pay your delegates for making decisions under your personal directive, you must say that they can be paid. Nova Scotia law says that delegates cannot be paid to make decisions under your personal directive, unless you say in your personal directive that you want to pay them. Pick one of the following
	option	My delegate is my spouse or a relative.
	option	I want one or more delegates to be paid for making decisions under this personal care directive.
	option	Invalid Input Repaying your delegates� costs If you want your delegate to be repaid for any costs they must pay while acting as your delegate, you must say that. Even if you do not say so in your personal directive, your delegates can be repaid for reasonable costs while acting as your delegates. However, the law is not completely clear. To be sure that your delegates can be repaid for their costs, you should fill out this section. Pick one of the following
	option	I want my delegates to be repaid for costs while acting as my delegates.
	option	Invalid Input < PrevNext > Review and Finalize Review the personal directive below the submit button. You can change any of your answers by using the Prev/Next buttons. If you are finished making your personal directive, click Submit to create a page you can sign. After you click Submit, a page will appear with a link so you can download a pdf of your responses with a signing page. If you give your email address below, we will ALSO email a copy of the pdf. Will you be able to
	option	Yes (will create a document you can sign)

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