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我的心声MyVoice表达我对今后医疗护理的意愿预先安排护理计划指南AdvanceCarePlanningGuideSimplifiedChineseLibraryandArchivesCanadaCataloguinginPublicationMyVoice--ExpressingMyWishesforFutureHealthCareTreatment.
Includesindex.
ISBN978-0-7726-6524-91.
Advancedirectives(Medicalcare)--BritishColumbia--Popularworks.
I.
BritishColumbia.
MinistryofHealthII.
Title.
R726.
2M92011344.
71104'197C2011-909048-1Healthauthoritydocumentprintingreferencenumbers:FH:349976IH:807025NH:1752PHSA:PHSA240VCH:00089414VIHA:904442013年2月使用本手册纯属自愿.
本手册旨在增进您与您的至亲或医护人员之间的沟通,就可能适合您的预先计划护理方案进行交谈.
此外,这里所提供的表格均反映了出版之日的法律,法规可随时间而变.
本指南不可取代医学或法律意见.
致谢卫生厅(MinistryofHealth)感谢菲沙卫生局(FraserHealth)同意改编其《我的心声》练习本,与这本新的《省预先安排护理计划指南》配套使用.
其次,还要感谢许多医生和患者抽出自己的时间,提供宝贵的意见.
本指南由卫生厅与以下单位合作,共同编制完成,其中包括:thenorthernwayofcaring第1页目录引言为何预先安排护理计划很重要制订您的预先安排护理计划信仰、价值观和愿望生命维持系统和延长生命医疗干预措施预先计划护理的选项临时代作决定的人(TSDM)代理协议书预先指示书代理协议书和预先指示书持久授权书更改或取消您的预先安排护理计划术语定义整理您的文件我的预先安排护理计划我的预先安排护理计划——摘要我的临时代作决定人(TSDM)名单我的信仰、价值观和愿望我的代理人:标准代理协议书(RA7)和强化代理协议书(RA9)代理协议书(第7条)表1:代理人或候选代理人证书表2:监察员证书表3:代成人签字者的证书表4:证人证书代理协议书(第9条)我的预先指示书资料适合放进钱包的小卡23556891114161920222527283032344041424344505252第2页引言参与决定自己的医疗护理是至关重要的.
有可能会出现这样的时刻,您因生病或受伤而没有能力向医护人员表达您对治疗的愿望.
通过提前计划安排,您可确保您的家人、朋友和(或)医护人员了解您的愿望,并可确保这些愿望得以遵照执行.
新版的无能力(或个人)计划法规于2011年9月1日在B.
C.
省生效.
该法规为成人提供更多的选择,表达自己对今后医疗护理决定的愿望,并允许有能力的成人制订计划,概述他们基于自己的信仰、价值观和愿望而同意或拒绝的医疗护理.
如果没有作决定(计划),B.
C.
省的医疗护理同意法规就医护人员必须选谁代病人作决定的事宜,给予受法律约束的医护人员专门的指引.
本指南及其后半部的练习部分将有助于您完成预先安排护理计划,概述一旦您无法对医疗护理作决定时,您对这些决定的愿望.
这可有助于您考虑哪些事情对您很重要,将您的信仰和愿望记录成文,从而有助于您制订最适合您的预先安排护理计划.
练习部分仅有英文版.
您可请律师、公证员、翻译、可信赖的朋友或会说英语的家人,帮您完成您的预先安排护理计划,填妥表格.
基于您所选的预先安排护理计划,可能会要求您填写一些法律表格,确保您的愿望得以遵照执行.
本指南附有表格,您可无需借助于律师或公证员即可填妥,如果妥当地填好这些表格,它们将具有法律效力.
对于复杂的情况,我们建议您寻求法律意见,确保这些表格和您所填的内容可满足您的需求.
第3页为何预先安排护理计划很重要只要您能够明白医生、护师、注册护士和(或)其他医护人员,并能与他们沟通,就会要求您自行决定您的医疗护理.
但是,今日不知明日事.
一场严重事故或大病会使您没有能力在您需要医疗护理时,自行决定您的医疗护理,而预先安排护理计划则可使之成为可能,这项计划可根据您的愿望,就您的医疗护理事宜,为家人或亲密的朋友和医护人员提供指引.
预先安排护理计划可解答以下问题:您想要谁来为您决定您的医疗护理如果医护人员建议一些医疗护理方案,您同意或拒绝哪些方案在某些情况下,您会同意或拒绝使用生命维持系统和延长生命医疗干预措施吗如果您需要住院治疗,不能在家中接受治疗,您更愿意怎么做玛丽54岁,离异,喜欢运动,有两个已成年的孩子.
两个月前,她在骑车时,被车撞倒了.
她现在仍然不省人事,需要借助呼吸机进行呼吸.
医生说玛丽有永久性脑损伤,无法复原.
她即使苏醒了,也再也不能自行行走、讲话或自主呼吸.
她身边常有她的两个女儿相伴.
现在玛丽的双肺正在抗击感染,非常不适.
医生说玛丽可能会在数周内死亡,建议取下玛丽的呼吸机,这样可让她更舒适地自然死亡.
她的一个女儿认为这是最佳方案,但是另一个女儿现已怀孕六个月,她却想尽一切可能实施医疗干预,直到玛丽的第一个外孙(外孙女)出世.
第4页如果玛丽制订了预先安排护理计划,让大家知道她对今后医疗护理的愿望,就可有助于她的女儿们和医护人员更了解她的信仰、价值观,以及在这种困境时她对医疗护理的愿望.
这项计划可在决定其医疗护理时提供指引,而这些决定是玛丽在能自我决定的情况下想为自己作的决定.
预先计划护理涉及到您与至亲、友人和医护人员的谈话,让他们知道,一旦您没有能力表达您自己的决定时,您想要或拒绝的医疗护理.
将您的信仰、价值观和您对今后医疗护理的愿望写下来,这就是预先安排护理计划.
您的预先安排护理计划也可包括附加的法律文件.
在不列颠哥伦比亚省,医护人员应尊重成人在其有能力时所表达的医疗护理愿望.
无论您是否在预先安排护理计划中说出您的愿望,医护人员都会向您建议医学上适当的医疗方案.
制订预先安排护理计划让其他人知道您想要为自己作的决定,并且让您的家人和朋友获得将来所需的知识和方法.
预先安排护理计划是一种选择,如果您的家人和朋友被要求为您决定重大的医疗护理,这种选择将有助于减轻他们可能要面对的某些压力.
第5页制订您的预先安排护理计划信仰、价值观和愿望预先计划护理要先考虑您的信仰、价值观和您对今后医疗护理的愿望,并要与家人或朋友和医护人员谈论这方面的问题.
当您所信赖的人了解您在今后医疗护理的问题上所看重的事情时,他们就会更容易地代您作决定.
下面所举的例子可帮您想出哪些事情对您很重要.
使我的生活充满意义的三件事:与家人和朋友共度时光热爱我的宠物、音乐、艺术、园艺、工作、爱好、新鲜空气、运动实践我的信念当我想到我死时会是怎么样的时候,如果能做到以下几点,我会感到放心:知道如果我有任何类型的疼痛,都会得到止痛处理相信我会得到良好的照料,我的家人仍陪伴在我的身边相信死后会有些东西,即使我不知道这会是什么当我想到死亡,我担心:我可能呼吸困难我可能有不受控制的疼痛我可能感到孤单在我弥留之际,我想要:我的家人在身边有人握着我的手我的宗教领导人来看我听大家温柔地谈起我一生中的幸福时光听我喜欢的音乐无论天气如何,都开着窗第6页生命维持系统和延长生命医疗干预措施考虑并讨论一下您对使用生命维持系统和延长生命医疗干预措施的愿望,这很重要,尤其是如果您有重病或有生命危险的疾病.
您的预先安排护理计划可涉及不同的情况,比如说,在常规手术期间和术后的住院医护、万一发生事故的医护抑或临终关怀的决定.
医生和其他医护人员始终会根据临床评价,提供医学上适当的医疗护理,医护人员要确保始终知道并处理任何像疼痛、头晕、恶心、出血或感染等症状.
只要您能理解和沟通,医护人员会向您解释最适合您的医学上适当的医疗护理方案,包括任何风险、益处或可选的方案,他们还会问您是否有任何疑问,是否想接受或拒绝这种医疗护理.
最难作的决定有些涉及使用生命维持系统和延长生命医疗干预措施.
医疗干预措施可包括帮助呼吸的呼吸机、管饲进食、肾透析或使心肺复苏的心肺复苏术(cardiopulmonaryresuscitation,英文缩写为CPR),当医护人员相信采取这些治疗措施在医学上是恰当的,就会实施.
以下的问题可帮您考虑,将来您想接受或拒绝使用生命维持系统和延长生命医疗干预措施.
如果您有慢性病:我的健康状况处于什么阶段病情可能会如何发展我的病情会影响我的记忆或今后我为自已作决定的能力吗我的病情有生命危险吗我因此病可能需要什么样的生命维持系统或延长生命医疗干预措施我的医护人员建议我应在我的预先安排护理计划中,考虑和处理哪些问题第7页如果您有生命危险的疾病或伤害,您是否要接受或拒绝以下治疗措施:心肺复苏术全部、部分或无需生命维持系统或延长生命医疗干预措施,而医护人员认为从医学的角度这些措施是适当的试用生命维持系统和延长生命医疗干预措施一段时间,如果病情不会得到改善,允许自然死亡您或许想问自己——"如果这意味着我不能再活下去,我想用生命维持系统或延长生命医疗干预措施":以我现在的方式,享受我的人生和参与各项活动吗离开病榻、步行或自己到外面去认得我的亲属或朋友,并与他们进行有意义的沟通为自己着想第8页预先计划护理的选项一旦您没有能力自行表达您的愿望和指示,以下几种方案可供选择.
您的个人情况和您想制订的预先安排护理计划的类型将会影响您所选的方案.
就您的信仰、价值观和愿望,与家人或朋友和医护人员进行交谈;写下您的信仰、价值观和您对今后医疗护理的愿望;写下有资格成为您"临时代作决定的人"名单,他们的联系方式.
基本的预先计划护理每一份预先安排护理计划应包括以下三点:标准代理协议书:第7条强化代理协议书:第9条预先指示书预先计划护理的选项根据您的预先计划护理的需要,以下各项可供选择:持久授权书允许您指定一人决定日常财务管理、个人护理和一些医疗护理.
不允许此人代您拒绝生命维持系统或延长生命医疗干预措施.
允许您指定一人决定个人护理和一些医疗护理,包括代您决定接受或拒绝生命维持系统或延长生命医疗干预措施.
允许您直接向医护人员阐述您对接受或拒绝医疗护理的决定,包括生命维持系统或延长生命医疗干预措施.
当预先指示书涉及在需要决定医疗护理时的有关决定,则必须得以遵照执行.
没有人会被要求代您作决定.
允许您指定某人在一旦您没有能力的情况下,代您决定财务和法律事务.
第9页临时代作决定的人(TSDM)如果从法律的角度,您尚未指定一人(代理人)在您没有能力为自己决定医疗护理时,代您作此决定,在这种情况下,则可选出临时代作决定的人(英文缩写为TSDM).
临时代作决定的人由您的医生或其他医护人员从您填写的名单上选出,这份名单上有资格人选的顺序要依照B.
C.
省法律来确定.
能够成为临时代作决定的人,必须年满19岁或以上,有能力,与您无争端,并且在过去的一年与您有联系.
必须按所列出的顺序找名单上的人:1.
您的配偶(已婚、同居、同性,共同生活的时间长短没有关系)2.
儿子或女儿(19岁或以上,排行没有关系)3.
父母(父亲或母亲,可以是养父母)4.
兄弟或姐妹(排行没有关系)5.
(外)祖父母6.
(外)孙子女(排行没有关系)7.
任何与您有血亲或收养关系的人8.
亲密的朋友9.
直系姻亲(姻亲、继父母、继子女等)您不可更改名单上的顺序.
对于列在名单下方的人,如果在此人上方的所有人都没有资格或无法履行该项职能,您的医护人员则只能选此人作为您的临时代作决定的人.
如果您知道您想要列在名单上下方的某人为您决定医疗护理事务,那么您应使用代理协议书表,从法律上指定此人作为您的代理人.
本指南的后面附上了两种不同的代理协议书表,务必要用符合您需求的那一份.
下一部分将有更多关于这两种代理协议书差异的信息.
您的临时代作决定的人从法律上被要求作的决定,应尊重您的意愿.
如果您已讨论过预先安排护理计划,并写下您的信仰、价值观和愿望,您的临时代作决定的人在被要求代您决定医疗护理时,将会知道并能说出您的愿望.
第10页为以防万一,选出临时代作决定的人,如果您对此人感到满意,您的预先安排护理计划将包括以下几点:与您的至亲或可信赖的朋友讨论您的信仰、价值观和愿望;写下您的信仰、价值观和愿望(第30页);以及填写您的临时代作决定的人名单(第28页),他们的联系方式,如果需要临时代作决定的人时,医护人员可能按顺序联系他们.
帕特和汤姆选择将他们的信仰、价值观和愿望记录成文,出于以下原因,他们仅填写了他们的临时代作决定人名单:帕特和汤姆长期关系稳定;他们彼此互信,相信另一方会尊重他们的信仰、价值观和愿望,为自己作出好的决定;作为配偶,他们都在另一方的临时代作决定人名单之首;以及帕特与她的成年孩子和母亲谈过她的信仰、价值观和愿望.
如果汤姆无法履行该项职能,他们俩人就会成为下一个临时代作决定的人.
帕特47岁,是一位文职人员,身体健康状况良好,她居住在北方的一座小城镇.
她与汤姆已结婚24年,汤姆49岁,他们有三个孩子,这三个孩子的年龄分别是20岁、17岁和14岁.
两个年龄小的孩子住在家里,老大在去年离开家去上大专.
过去这几年,帕特失去了几位亲友,经历此事之后,她开始考虑自己对今后的医疗护理的决定,她跟汤姆谈了她的情感和担忧,结果汤姆跟帕特一样,也有许多同感.
他们一起决定要做预先计划护理,这样他们将会知道对方对今后的医疗护理决定的愿望.
第11页代理协议书不列颠哥伦比亚省的成人如果想要特定的人代其作某些类型的决定,则可在代理协议书中指定一名代理人.
代理协议书有两种.
标准协议书:第7条代理协议书第7条代理协议书允许您指定代理人,决定您的日常财务管理事务、个人护理和一些医疗护理,这种协议不允许您的代理人代您决定涉及拒绝生命维持系统或延长生命医疗干预措施的医疗护理.
对于医护人员评价为没有能力订立强化(第9条)代理协议书的成人,他们可选用标准协议书.
第7条代理协议书允许能力较低的成人预先计划一些护理,比如说,有某些发育性残疾或脑损伤(脑疾)影响认知能力的人.
对于有能力订立第9条代理协议书的成人,如果第7条代理协议书可满足他们的需求,则可选订这种协议书.
完成第7条代理协议书作为您的预先安排护理计划的一部分,要涉及以下几点:与您的至亲或可信赖的朋友讨论您的信仰、价值观和愿望;写下您的信仰、价值观和愿望(第30页);使用第7条表格,在代理协议书中,指定您的代理人并写下您的指示(第34页);以及填写您的临时代作决定的人名单,他们的联系方式.
万一您的代理人弃权或无法履行该项职能,或者需要决定生命维持系统或延长生命医疗干预措施,在需要临时代作决定人的情况下,医护人员可能会联系他们(第28页).
第12页因为考虑到所有相关的因素和下面几点,迈克有资格完成第7条代理协议书:他可以沟通,表达他想要有一个代理人帮他决定有关他个人护理、日常财务和一些医疗护理的事务,并且他明白他的代理人可能会作或不作影响他的决定;他信任他的朋友本恩,知道本恩会关照他;他知道并理解,他不要本恩作有关拒绝生命维持系统或延长生命医疗干预措施的决定;本恩符合资格,并已同意被定为他的代理人;以及虽然他的弟弟住在B.
C.
省外,他与迈克保持联系,如果需要决定有关生命维持系统的医疗护理,他弟弟则有资格成为迈克的临时代作决定的人.
强化协议书:第9条代理协议书第9条代理协议书允许您指定代理人,决定您的个人护理和医疗护理事务,包括决定接受或拒绝生命维持系统和延长生命医疗干预措施.
在第9条代理协议书中指定的代理人不可决定您的财务事务.
在一旦您没有能力的情况下,要有人为您作账务方面的决定,出于此目的,您可用持久授权书表(请参阅第19页,了解更多信息)指定一个人(即律师).
迈克38岁,10年前经历过一场严重的摩托车事故,因为这场事故,他头部受伤,落下瘫痪,有持续性的记忆问题.
他单身,父母已故,有一个与他关系密切的弟弟,他弟弟居住在省外.
在过去的八年间,迈克一直独自一人住在他的公寓里.
借助于特制的设备和上门服务的护工,他能尽可能地独立.
他最要好的朋友本恩每周带他去购物,去看医生.
虽然迈克说自己的记忆在去年更差了,但是他的身体一直很好,这种情况使他很难作决定,迈克变得越来越依赖本恩,确保他能按时支付账单,预约医生,与本恩一起赴约看病.
迈克的社区护士已建议他应指定一名代理人,帮他处理个人、财务和一些医疗护理的决定.
第13页完成第9条代理协议书作为您的预先安排护理计划的一部分,要涉及以下几点:与您的至亲或可信赖的朋友讨论您的信仰、价值观和愿望;写下您的信仰、价值观和愿望(第30页);使用第9条表格,在代理协议书中,指定您的代理人并写下您的指示(第44页);以及填写您的临时代作决定的人名单,他们的联系方式.
一旦您的代理人弃权或无法履行该项职能,在需要临时代作决定人的情况下,医护人员可能会联系他们(第28页).
格笛普74岁,于10年前与妻子兰尼一起移居加拿大,兰尼不怎么会说英语.
格笛普身体欠佳已有七年了,他有肾病、糖尿病和高血压,每周要做三次肾透析.
他有充血性心力衰竭,每隔几个月病情就会加重.
他和兰尼与大儿子吉特一起住,吉特帮着照顾他,陪他去看医生.
格笛普还有另外五个孩子,这五个孩子都住在附近,与他们所有的人关系良好.
随着格笛普的健康明显地每况愈下,他的医生建议他应预先计划护理,以便让大家知道他的愿望,一旦格笛普没有能力为自己作决定,大家都清楚谁将代他作决定.
格笛普与妻子和孩子们谈过话,明确地表达他不愿意住院或到护理院,他更愿意在家里,直至走完人生.
他担心会有疼痛,并且不愿意靠机器来延长生命.
除了他的健康问题外,他还想成为器官捐献者.
他决定在他没有能力的情况下,由吉特代他决定医疗护理事务.
第14页出于以下原因,格笛普选择完成第9条代理协议书:吉特不在临时代作决定人名单上之首,为了可让他决定格笛普的医疗护理,必须指定他作为格笛普的代理人;格笛普知道吉特无需翻译即可轻松地与医生交谈;格笛普相信吉特会在尊重他的信仰、价值观和愿望的前提下,决定他的医疗护理,并且他会请兰尼参加重要的会谈;以及第9条代理协议书将允许吉特接受或拒绝生命维持系统和延长生命医疗干预措施.
格笛普可从其他孩子中指定一人,作为他的候选代理人,以防吉特弃权.
此外,格笛普还可选择制订预先指示书,在第9条代理协议书中注明,医护人员可直接遵照他的预先指示书行事,而无需要求他的代理人作决定.
这些选择可确保格笛普的医疗护理愿望和指示得以遵照执行.
预先指示书预先指示书允许有能力的成人清晰地阐述其接受或拒绝医疗护理的决定,包括生命维持系统和延长生命医疗干预措施,并直接向医护人员提供这些指示和决定.
只要您的预先指示书涉及到时您所需的医疗护理,就必须执行这份预先指示书.
如果需要决定医疗护理,但却未在您的预先指示书内加以说明,只有在这种情况下,才会选临时代作决定的人.
完成预先指示书作为您的预先安排护理计划的一部分,要涉及以下几点:与您的至亲或可信赖的朋友讨论您的信仰、价值观和愿望;写下您的信仰、价值观和愿望(第30页);在预先指示书中概述您对今后医疗护理的决定(第50页);以及填写您的临时代作决定的人名单,他们的联系方式.
如果需要临时代作决定的人决定医疗护理,而这一项却未在预先指示书中加以说明,则医护人员可能会联系他们(第28页).
第15页出于以下原因,珍妮选择完成预先指示书:珍妮没有任何家人,医护人员要选她的好友作为珍妮的临时代作决定的人时,她的好友可能无法履行该项职能;;珍妮可以阐明她对使用生命维持系统和延长生命医疗干预措施的愿望和指示,她想何时开始、继续或停止使用;以及珍妮的医生就预先计划护理之事与她谈过话,并拿到一份她的预先指示书,在这之后,她的医生更了解珍妮、她的希望和她对今后的愿望.
珍妮可与她的朋友罗斯或她所信赖的其他人谈谈她的愿望,确保将他们列在她的联系人名单上,在需要时,他们将作为她的临时代作决定的人.
她也可制订一份持久授权书,授权一个人在她没有能力自行管理她的财务和财产的情况下,代她处理这些事务(请参阅第19页,了解更多信息).
珍妮58岁,24年前从中国移居加拿大,她未婚,没有至亲,她不喜欢交流思想,养了一只猫,有少数朋友,包括她的好朋友罗斯,罗斯经常外出旅行.
珍妮一直很健康,直到一个月前,她在爬一座很陡的小山时,感到胸部剧痛.
做了几项检查后,珍妮的医生说她的动脉正变得阻塞,她的胆固醇太高,心脏病发作的风险极高.
医生就她的病情开了些药,建议她应戒烟,并将她转诊到心脏病专科医生做进一步的治疗.
他还建议她应考虑预先计划护理,因为她没有至亲,故要确保大家知道她的医疗护理决定,并且医护人员可尊重她的决定.
如果病情加重,珍妮可能需要生命维持系统和延长生命医疗干预措施,在考虑这一点之后,她选择填写一份预先指示书.
第16页代理协议书和预先指示书成人的个人情况不同可影响他们的选择,是选择代理协议书、预先指示书,还是仅仅与至亲和朋友谈论自己的信仰、价值观和愿望,然后明确临时代作决定人的联系方式.
不列颠哥伦比亚省的个人计划法规也提供了同时用代理协议书和预先指示书的选项.
如果您有代理协议书和预先指示书这两份文件,并要您的医护人员在无需要求您的代理人作决定的情况下,遵照执行您的预先指示书,您则必须在您的代理协议书中说明这一点.
完成代理协议书和预先指示书作为您的预先安排护理计划的一部分,要涉及以下几点:与您的至亲或可信赖的朋友讨论您的信仰、价值观和愿望;写下您的信仰、价值观和愿望(第30页);用第7条(第34页)或第9条(第44页)表格在代理协议书中指定您的代理人;在预先指示书中概述您对今后医疗护理的决定(第50页)【注:如果这是您的愿望,您则需要在您的代理协议书中说明,医护人员可根据您的预先指示书中的指示行事,而无需征求您代理人的同意】;以及填写您的临时代作决定的人名单,他们的联系方式.
如果您的代理人弃权或无法履行该项职能,并且您的预先指示书不适用,在需要临时代作决定的人决定医疗护理时,医护人员可能会联系他们(第28页).
第17页第7条代理协议书和预先指示书除了第7条代理协议书外,制订预先指示书可直接向医护人员提供专门的指示,只要您在代理协议书中写明,可在无需要求您的代理人代您决定医疗护理的情况下,执行您的预先指示书.
出于以下原因,玛丽选择完成第7条代理协议书和预先指示书:当玛丽生病,且托尼又不在家时,其代理人珍妮将会决定玛丽的日常财务.
玛丽可限制珍妮的权限,只委托她在玛丽的精神病症状达到特定阶段时,才可决定医疗护理;玛丽不想要珍妮决定拒绝生命维持系统;玛丽的预先指示书允许她直接向医护人员详细地指示她自己的医疗护理;预先指示书将确保玛丽即使她在需要治疗时却拒绝治疗的情况下,能够得到她所需的医学上适当的医疗护理.
玛丽34岁,在她16岁时被确诊患有早期精神病,并接受治疗.
多数时候她都很正常,可控制自己的症状,照顾自己.
她与托尼结了婚,托尼定期离家去外面工作.
她的姐姐珍妮住在附近,只要她有时间,就会来帮玛丽.
玛丽不好时,通常是精神病症状复发了.
出现这种情况,她变得没有能力照料自己和她的家.
虽然她可以在家里接受评估和治疗她的症状,但是在其他时候她都被送到当地医院的精神病科住院部,这一周期每一二年要重复一次.
当玛丽的症状加重时,她有时拒绝治疗,而这种治疗却可使她的病情稳定下来.
在上次住院后,玛丽跟托尼、她的精神病医生和珍妮谈了出现这些情况时的长期护理计划问题.
在上次看病时,玛丽的家庭医生建议她应预先计划护理,就其今后的医疗护理和个人计划作出决定;另建议玛丽应指定代理人,确保如果她需要住院,而托尼又不在家,她的护理和日常财务需求可得到处理;还建议玛丽要制订预先指示书,以确保无论何时她的精神病症状复发,都可尽早得到治疗.
玛丽选择订立第7条代理协议书和预先指示书.
第18页第9条代理协议书和预先指示书除了第9条代理协议书外,制订预先指示书可直接向医护人员提供专门的指示,只要您在代理协议书中写明,可在无需要求您的代理人代您决定医疗护理的情况下,执行您的预先指示书.
出于以下原因,唐恩选择完成第9条代理协议书和预先指示书:唐恩与许多人有密切的关系,他们都非常关心他.
如果唐恩生病,没有能力为自己作决定,则有可能许多人会相信他们能够最好地表达唐恩的愿望;在没有指定的代理人情况下,唐恩的医护人员必须选择希拉作为临时代作决定的人来作决定,而这可能会使他的女儿们感到不安;通过在预先指示书中说明他对医疗护理的指示,唐恩的医护人员将会知道他的愿望.
如果唐恩想要他的第一任前妻和(或)他的小女儿卡伦做他的代理人,则他可指定一人作为他的代理人,另一人作为他的候选代理人.
唐恩68岁,是个生意人,两个月前他发现得了前列腺癌.
虽然唐恩有50多年的烟龄,慢性咳嗽,有点超重,但他没有其他的健康问题.
去年他的一位朋友因前列腺癌去世,他的哥哥于5年前死于结直肠癌.
唐恩离异两次,有三个成年女儿,她们都生活在同一座城市.
他与他的第一任前妻仍是好友,两个月前,他与他的新伴侣希拉开始同居,他的女儿们对希拉不大了解.
他与小女儿卡伦的关系很好,她知道他的愿望.
唐恩去看医生,做常规例行检查,并跟医生讨论他的担忧.
他的医生建议他应考虑预先计划护理,考虑一旦他没有能力自行决定健康问题时,由谁来为他作决定.
唐恩选择订立第9条代理协议书和预先指示书.
第19页持久授权书持久授权书允许成人指定另一人(即他的律师)就其财务和法律事务作出决定,此人(律师)受委托在一旦这位成人没有能力时,行使执行权.
律师被给予的权限可根据您的需求专门设定.
例如,权限范围可从有权将支票存入您的支票账上到完全有权处理您所有的资产.
律师不可决定医疗护理.
代理协议书是指定某人代您决定医疗护理的唯一的方法.
资料可上网查找持久授权书表,网址:www.
ag.
gov.
bc.
ca/incapacity-planning/pdf/Enduring_Power_of_Attorney.
pdf要了解更多信息,可到不列颠哥伦比亚省公共监护及受托人(PublicGuardianandTrusteeofBritishColumbia)的网站查找,网址:www.
trustee.
bc.
ca律师推荐服务中心(LawyerReferralService,网址:www.
cba.
org/BC/Initiatives/main/lawyer_referral.
aspx)由加拿大律师公会不列颠哥伦比亚省分会负责运作,该中心可提供初步的律师咨询服务,收费低,时间可长达30分钟.
电话接线服务周一至周五,早上8:30到下午4:30,低陆平原地区电话:604687-3221,或B.
C.
省免费长途电话:1800663-1919.
第20页更改或取消您的预先安排护理计划您的个人情况会随时间而变.
只要您有能力,就可以在任何时候更改或取消(废除)您的预先安排护理计划,这包括代理协议书和预先指示书.
务必要定期检查您的预先安排护理计划,并在您相信有必要时修改这份计划.
在检查期间,询问您的代理人或可能成为您的临时代作决定的人,他们是否仍愿意且能够代您作医疗护理的决定.
检查您在预先安排护理计划中所写的愿望,包括在您的代理协议书或预先指示书所写的任何专门的指示.
在更改或取消您的预先安排护理计划之前,要确定您对自己目前的健康状况和可提供给您的任何新的医疗护理有最新的了解.
如果您想更改和更新或取消您的预先安排护理计划,包括代理协议书或预先指示书(如果您订了这两份文件),以下的说明告诉您该怎么做.
1.
更改您的预先安排护理计划摘要、临时代作决定人的联系名单和(或)信仰、价值观和您对医疗护理的愿望,包括延长生命医疗干预措施:销毁旧的那几页,重新填写新的那几页.
要确定在新的那几页上根据要求签字并注明日期.
如果您以前未曾指定代理人或制订预先指示书,现在仍不想这么做,请跳到第4点.
如果您想指定代理人【第7条(第34页)或第9条(第44页)】或制订预先指示书(第50页),请填妥表格,并通知您的家人、朋友和医护人员.
2.
更改您的代理协议书(第7或9条)和(或)预先指示书,您有两种选择:在您现有的代理协议书或预先指示书上直接更改,然后按原先订立原文件的同样方式,在证人面前签署这些文件,并注明日期;或重新制订代理协议书或预先指示书,取代旧的文件,并取消您旧的代理协议书或旧的预先指示书(请参阅第3点).
第21页3.
取消现有的代理协议书或预先指示书要取消(废除)现有的代理协议书或预先指示书,您必须:销毁原先的文件或另外写一份文件,说明您要取消旧文件的意图;以及向被指定作为您的代理人的人(包括任何候选的代理人或监察员)提供一份书面的取消(废除)通知.
4.
更改通知在更改或取消您的预先安排护理计划之后,您应:通知任何家人、朋友、代理人(如果您有代理人)和医护人员,您已更改或取消您的预先安排护理计划.
如果您曾订过代理协议书或预先指示书,还包括更改这些表;向您的家人、朋友、代理人(如果您有代理人)和医护人员要回您旧的预先安排护理计划.
如果您有旧的代理协议书和预先指示书,还包括这些相关的文件,以便您可以销毁它们;向您的至亲或朋友和医护人员提供您新改好的预先安排护理计划,包括代理协议书和预先指示书(如果您订了这些文件);务必要确保您的医生和其他医护人员知道您最新的医疗护理愿望和指示.
如果您更新了您的预先安排护理计划,包括您的代理协议书或预先指示书,要确保您知会了所有相关的医护人员.
务必要请他们检查,并酌情更新或取消任何不适用的医嘱.
第22页术语定义预先安排护理计划是指有能力的成人的书面愿望或指示摘要,如果医生或其他医护人员要代作决定的人代这位成人决定医疗护理,则这份摘要可为这位代作决定的人提供指引.
预先计划护理是指一个过程,在这一过程中,有能力的成人在其可能没有能力为自己作决定之前,提前与其至亲(朋友)和医护人员谈及有关其信仰、价值观和对医疗护理愿望的事宜.
预先指示书是指有能力的成人的书面指示,该指示直接向其医护人员说明其同意或拒绝的医疗护理.
当这位有能力的成人一旦没有能力时,这份指示书即产生效力,它只适用于在此预先指示书注明的医疗护理条件和治疗.
允许自然死亡是指病人在临终时,接受对一些症状实施医学上适当的医疗护理,比如疼痛或呼吸短促.
心肺复苏术(英文缩写为CPR)是指一种急救措施,当一个人的心脏和(或)肺意外地停止运作时,用此术使其心肺复苏.
心肺复苏术可包括反复按压病人的胸部,施人工呼吸,使病人肺部充气,提供氧气.
透析是指一种医疗干预措施,当病人的肾脏不能再净化血液时,就采用这种医疗干预措施为病人清洁血液.
临终关怀是指在生命最后阶段提供的治疗,这种治疗可称为支持性治疗、姑息治疗或症状控制.
临终关怀处理身心和精神方面的问题,侧重于安抚、尊重决定和为家人提供支持.
这项服务由一组跨学科的医护人员负责提供.
持久授权书是指一份文件,成人用这份文件授权另一人(即他的律师)就这位成人的财务、生意和财产作决定.
此人(律师)受委托在这位成人一旦没有能力时,行使执行权,或者在这位成人一直没有能力时继续行使执行权力.
律师不可决定医疗护理.
医护人员是指持照的、经认证的或注册的专业人员,他们根据《医疗专业法》(HealthProfessionsAct)(如医生、护师、注册护士)和《社会工作者法》(SocialWorkersAct)提供医疗护理.
第23页医疗护理是指出于治疗、预防、缓解、诊断、整容或其他医疗护理目的而做的任何项目,并可是在一段时间内实施一系列类似的治疗或护理(如控制血压的药、伤口护理),或者出于各种护理目的长达一年的计划.
没有能力的(没有能力)是由医护人员来确定,该人员必须根据成人是否显示出他们明白以下各项而定:1.
向其提供的有关其健康状况的信息;2.
建议的医疗护理方案的特点,包括风险、益处和备选方案;以及3.
适用于其状况的信息.
生命维持系统和延长生命医疗干预措施是指诸如管饲进食、呼吸机、肾透析、药物和心肺复苏术的医疗护理.
当这种医疗的目的是为了延续或延长生命时,就被视为医学上适当的医疗护理.
医学上适当的医疗护理是指基于医护人员的健康评价而由其提供的医疗护理,这种医疗护理符合病人的病情和医疗目的.
监察员是指可能在代理协议书中被指定的人,以确保代理人履行其职责.
护师是指注册护士,该护士已满足被注册和使用护师职称的专业要求.
他们提供扩展的护士服务,包括诊断、开药、开检查单和控制常见急性疾病和慢性病.
个人监护人(此人的委员会)是指法庭指定的人,一旦成人没有能力自行决定时,由此人代这位成人决定健康和个人事务.
个人护理是指个人日常起居需求,比如生活安排、饮食、衣物、卫生、锻炼和安全.
授权书是指一份文件,该文件指定由有能力的成人授权的人(即律师)代其决定财务、生意和(或)财产事务.
律师不可决定医疗护理.
第24页代理人是指由有能力的成人在代理协议书中指定的19岁或以上的人,在这位成人没有能力作决定的情况下,代其决定医疗护理.
代理协议书(英文缩写为RA)是指一份文件,在该文件中有能力的成人指定其代理人在其没有能力的情况下,代其决定医疗护理和其他事务.
代理协议书有两种:1.
第7条代理协议书:成人可授权代理人代其决定日常财务管理、个人护理和一些医疗护理,不包括决定拒绝生命维持系统和(或)延长生命医疗干预措施.
2.
第9条代理协议书:成人可授权代理人代其决定个人护理和医疗护理,包括决定接受或拒绝生命维持系统和延长生命医疗干预措施.
配偶是指一个人,此人:a.
与另一人结了婚,并且根据《离婚法》(加拿大)的定义,没有与另一人分居和分离;或b.
与另一人以类似婚姻的关系同居,包括同性的两人之间.
代作决定的人是指一个有能力的人,经授权代没有能力的成人决定医疗护理;还包括个人监护人(此人的委员会)、代理人和(或)临时代作决定的人.
临时代作决定的人(英文缩写为TSDM)是指由医护人员选出的有能力的成人,在需要医疗的情况下,此人代没有能力的成人决定医疗护理.
如果这位成人有预先指示书,说明在需要时的医疗,或如果这位成人有个人监护人或代理人,则无需选择临时代作决定的人.
管饲进食是指向不能用口进食的人提供营养的方法.
管饲进食涉及置放临时或永久性喂养管,可通过病人的鼻子也可经腹壁进入其胃,输入液体食物.
呼吸机是指一种机器,当病人不能自主呼吸时,用此机器向肺充气和吸气.
第25页整理您的文件PuttingYourPapersinOrder预先计划护理是一个良好的机会,让您将所有的个人计划文件归纳到一起,放到容易查找的地方.
这对应您要求负责处理您事务的人来说,将有助于他们在需要时可找到这些文件.
请阅读以下清单,并在适合您的方框和划线上填空.
我是器官捐献者(在www.
transplant.
bc.
ca网站上登记):是Yes不是NoIamanorgandonor(registeratwww.
transplant.
bc.
ca)我已在授权书上指定一名律师:是Yes不是NoIhaveappointedanattorneyunderapowerofattorney:律师姓名/Nameofattorney:我已在持久授权书上指定一名律师:是Yes不是NoIhaveappointedanattorneyunderanenduringpowerofattorney:律师姓名/Nameofattorney:可在何处找到我的授权书和(或)持久授权书:Wheretofindmypowerofattorneyand/orenduringpowerofattorneydocuments:我有遗嘱Ihaveawill:是Yes不是No可在何处找到我的遗嘱Wheretofindmywill:我有律师Ihavealawyer:是Yes不是No律师姓名/Nameoflawyer:电话/Phone:我有人寿保险保单Ihavealifeinsurancepolicy:是Yes不是No公司/Company:我已安排了殡葬(火化)事宜:Ihavemadefuneralandburial/cremationarrangements:是Yes不是No公司/Company:电话/Phone:其他文件/Otherpapers:第26页我的预先安排护理计划此练习部分仅有英文版.
您可请律师、公证员、翻译、可信赖的朋友或会说英语的家人,帮您完成您的预先安排护理计划,填妥表格.
本部分提供了您要制订您的预先安排护理计划所需的所有必要的方法和表格.
在每一页上方的说明将帮您确定您需要填那几页,我们将这些页面设计成可撕下的页面,方便您取用.
您只要填写您所选的法律文件所需的那几页.
如有必要,请查回本指南第一部分有关不同预先安排护理计划选项的阐述,帮您决定您要填写哪些文件,才可满足您对今后的医疗护理的需求.
第27页Page27MyAdvanceCarePlan-SummaryThissummaryisthecoverofyouradvancecareplan.
Fullname(pleaseprint):Signature:Datethisadvancecareplanwascompleted:dd/mm/yyyyThisisanupdateofmyadvancecareplan:YesNoMyadvancecareplanincludes(tickallthatapply):Mybeliefs,valuesandwishesMyTSDMlistMystandardrepresentationagreement(section7)-optionalForm1-CertificateofRepresentativeorAlternateRepresentativeForm2-CertificateofMonitorForm3-CertificateofPersonSigningfortheAdultForm4-CertificateofWitnessesMyenhancedrepresentationagreement(section9)-optionalMyadvancedirectiveform-optionalIhavegivencopiesofthisadvancecareplanto:Relationshiptome:Phone:Relationshiptome:Phone:Relationshiptome:Phone:Relationshiptome:Phone:ismyhealthcareprovider.
Phone:第28页Page28MyTemporarySubstituteDecisionMaker(TSDM)ListIfneeded,thislistwillbeusedbyyourhealthcareprovider(s)tochooseaTSDMforyou.
TheorderofthepeopleonthelistissetoutinB.
C.
lawandmaynotbechanged.
ToqualifyasaTSDM,thepersonlistedmustbe19,capable,havenodisputewithyou,andhavebeenincontactwithyouintheyearbeforeyouneedthehealthcare.
IfaTSDMisneededtomakeahealthcaredecisionforyou,yourhealthcareproviderwillchoosethefirstpersononthelistwhoisqualifiedandavailable.
Ifyouwanttospecifyonepersontomakehealthdecisionsforyou,youmustfullycompleteeitherastandard(p.
34)orenhanced(p.
44)representationagreement.
Spouse(includesmarried,common-law,same-sex-lengthoftimelivingtogetherdoesnotmatter)NamePhoneChildren(any-birthorderdoesnotmatter)NamePhoneNamePhoneParents(either-mayincludeadoptive)NamePhoneNamePhoneBrothersorSisters(any-birthorderdoesnotmatter)NamePhoneNamePhoneGrandparents(any)NamePhoneNamePhone第29页Page29Grandchildren(any-birthorderdoesnotmatter)NamePhoneNamePhoneAnyoneelserelatedtomebybirthoradoptionNamePhoneNamePhoneClosefriendNamePhoneNamePhoneApersonimmediatelyrelatedtomebymarriage(rankedequally)NamePhoneNamePhoneIknowaTSDMwillnotbechosentomakehealthcaredecisionsformeifIcompleteanoptionalrepresentationagreementformand/oranadvancedirectiveformwhichaddressesthehealthcareconditionIhavewhenthecareisneeded.
IalsoknowaTSDMwillbechosentomakehealthcaredecisionsformeifIhavenorepresentative,ifmyrepresentativeisunavailable,orifmyoptionalrepresentationagreementand/oradvancedirectivedoesnotaddressthehealthcareconditionIhavewhenthecareisneeded.
Iagree.
Name(print)SignatureDatesigned第30页Page30MyBeliefs,ValuesandWishesCompletethispageforalladvancecareplans,regardlessofwhetheryouchoosetocompletearepresentationagreementformoradvancedirectiveform.
Ifneeded,thisinformationwillhelpyoursubstitutedecisionmaker(courtappointedpersonalguardian,representativeorTSDM)makefuturehealthcaretreatmentdecisionsforyou.
Note:Ifyouwanttomakeanadvancedirectiveornamearepresentativeinarepresentationagreementwithspecificinstructionsaboutyourhealthcaretreatmentdecisions,besuretowriteyourinstructionsdirectlyonthoseforms.
Theinformationyouwriteonthesepagesisnotarepresentationagreementoranadvancedirective.
Mybeliefs(whatgivesmylifemeaning)第31页Page31Myvalues(whatIcareaboutinmylife)Mywishes(forfuturehealthcaretreatment,lifesupportandlife-prolongingmedicalinterventions)Name(print)SignatureDatesigned第32页Page32MyRepresentative-StandardAgreement(section7)Section7RepresentationAgreementForm(p.
34-39)Useasection7formifyouwantyourrepresentativetobeauthorizedtomakedecisionsaboutyourroutinefinancialaffairs,yourpersonalcareandsomehealthdecisions.
Asection7formdoesnotprovidearepresentativewiththeauthoritytorefuselifesupportandlife-prolongingmedicalinterventions.
InadditiontoaSection7RepresentationAgreementform,thefollowingcertificatesmustbecompleted(iftheyapply)fortheagreementtobeeffective:Form1:CertificateofRepresentativeorAlternateRepresentative(p.
40)Form2:CertificateofMonitor(p.
41)Form3:CertificateofPersonSigningfortheAdult(p.
42)Form4:CertificateofWitnesses(p.
43)MyRepresentative-EnhancedAgreement(section9)Section9RepresentationAgreementForm(p.
44-49)Useasection9formifyouwantyourrepresentativetobeauthorizedtomakedecisionsaboutacceptingorrefusinglifesupportandlife-prolongingmedicalinterventionsonyourbehalf,inadditiontootherhealthandpersonalcaredecisions.
第33页Page33第34页Page34PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIAREPRESENTATIONAGREEMENT(SECTION7)MadeunderSection7oftheRepresentationAgreementAct.
Theuseofthisformisvoluntary.
Beadvisedthatthisformmaynotbeappropriateforusebyallpersons,asitprovidesonlyoneoptionofhowaRepresentationAgreementmaybemade.
Inaddition,itdoesnotconstitutelegaladvice.
Forfurtherinformation,pleaseconsulttheRepresentationAgreementActandRepresentationAgreementRegulationorobtainlegaladvice.
Thisformreflectsthelawatthedateofpublication.
Lawscanchangeovertime.
Beforeusingthisform,youshouldreviewtherelevantlegislationtoensurethattherehavenotbeenanychangestothelegislationorsectionnumbers.
ThenotesreferencedinthisRepresentationAgreementarefoundattheendofthisAgreementandareprovidedforinformationonly.
1.
THISREPRESENTATIONAGREEMENTISMADEBYME,THEADULT:FullLegalNameoftheAdultFullAddressoftheAdult2.
REVOCATIONOFPREVIOUSREPRESENTATIONAGREEMENTSIrevokeallpreviousRepresentationAgreementsgrantingauthorityundersection7oftheRepresentationAgreementActmadebyme.
(SeeNote1–actionsthatmustbetakentorevokeapreviousRepresentationAgreement)(SeeNote2–effectofrevocationonaprevioussection7RepresentationAgreement)3.
REPRESENTATIVE(SeeNote3–namingaRepresentative)InamethefollowingpersontobemyRepresentative:Date(YYYY/MM/DD)FullLegalNameofRepresentativeFullAddressofRepresentative4.
ALTERNATEREPRESENTATIVE(OPTIONAL)(SeeNote3–namingaRepresentative)(StrikeoutthisprovisionifyoudonotwanttoappointanAlternateRepresentative.
)IfmyRepresentativedies,resignsinaccordancewiththeRepresentationAgreementAct,ismyspouse,asdefinedintheRepresentationAgreementAct,atthetimethatImakethisRepresentationAgreement,andourmarriageormarriage-likerelationshipsubsequentlyterminatesassetoutintheRepresentationAgreementAct,orbecomesincapable,thenInamethefollowingpersontobemyAlternateRepresentative:FullLegalNameofAlternateRepresentativeFullAddressofAlternateRepresentativePAGE1OF3第35页Page35PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIAFullLegalNameofMonitorFullAddressofMonitor5.
EVIDENCEOFAUTHORITYOFALTERNATEREPRESENTATIVE(SeeNote4–statutorydeclarationforevidenceofauthorityofAlternateRepresentative)(StrikeoutthisprovisionifyouarenotappointinganAlternateRepresentative.
)AstatutorydeclarationmadebymyRepresentative,myAlternateRepresentative(ifoneisnamed),ortheMonitor(ifoneisnamed),declaringthatoneofthecircumstancesreferencedinsection4ofthisRepresentationAgreementhasoccurred,andspecifyingthatcircumstance,issufficientevidenceoftheauthorityofmyAlternateRepresentativetoactinplaceofmyRepresentative.
6.
AUTHORITYOFREPRESENTATIVE(SeeNote5-whataRepresentativemayandmaynotbeauthorizedtodounderasection7RepresentationAgreement)Pursuanttosection7oftheRepresentationAgreementAct,IauthorizemyRepresentativeto:(IfyouwantyourRepresentativetohavebothtypesofauthority,donotstrikeouteitherofthefollowingprovisions.
IfyouwantyourRepresentativetohaveauthorityoveronlyoneofthefollowingmatters,strikeouttheprovisionoverwhichyoudonotwantyourRepresentativetohaveauthority.
Youmaynotstrikeoutbothtypesofauthority.
)a.
helpmemakedecisionsb.
makedecisionsonmybehalfaboutthefollowing:(StrikeoutanyofthefollowingmattersforwhichyoudonotwantyourRepresentativetohaveauthority.
)a.
mypersonalcare;b.
theroutinemanagementofmyfinancialaffairs,assetoutintheRepresentationAgreementRegulation;c.
majorhealthcareandminorhealthcare,asdefinedintheHealthCare(Consent)andCareFacility(Admission)Act;d.
obtaininglegalservicesformeandinstructingcounseltocommenceproceedings,exceptdivorceproceedings,ortocontinue,compromise,defendorsettleanylegalproceedingsonmybehalf.
7.
MONITOR(SeeNote6-whataMonitorisandwhetheroneisrequired)(StrikeoutthisprovisionifaMonitorisnotrequiredandyoudonotwanttonameaMonitor.
)InamethefollowingpersonasMonitorofthisRepresentationAgreement:8.
EFFECTIVEDATEThisRepresentationAgreementbecomeseffectiveonthedateitisexecuted.
PAGE2OF3第36页Page36PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIAPAGE3OF39.
SIGNATURESADULT'SSIGNATURETheAdultmustsignanddateinthepresenceofbothWitnesses.
DateSigned(YYYY/MM/DD)DateSigned(YYYY/MM/DD)SignatureofWitnessNo.
1PrintNameAddressWITNESSESTOADULT'SSIGNATURE(SeeNote7–informationforwitnesses)WITNESSNO.
1WitnessNo.
1mustsigninthepresenceoftheAdultandWitnessNo.
2.
DateSigned(YYYY/MM/DD)SignatureofWitnessNo.
2PrintNameAddressWITNESSNO.
2NotrequiredifWitnessNo.
1isalawyerormemberingoodstandingoftheSocietyofNotariesPublicofBritishColumbia.
WitnessNo.
2mustsigninthepresenceoftheAdultandWitnessNo.
1.
DateSigned(YYYY/MM/DD)SignatureofRepresentativePrintNameREPRESENTATIVEALTERNATEREPRESENTATIVE(StrikeoutifanAlternateRepresentativeisnotappointed.
)DateSigned(YYYY/MM/DD)SignatureofAlternateRepresentativePrintNameADULTANDWITNESSSIGNATURESREPRESENTATIVES'SIGNATURES(SeeNote8-whenaRepresentativemayexerciseauthorityunderthisRepresentationAgreement)(SeeNote9-additionalformsrequiredforthisRepresentationAgreementtobeeffective)IfwitnessisalawyerormemberoftheSocietyofNotariesPublicofBritishColumbia,checkrelevantboxbelow:lawyermemberoftheSocietyofNotariesPublicofBritishColumbiaPrintNameSignatureofAdult第37页Page37PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIASTATUTORYDECLARATONFOREVIDENCEOFAUTHORITYOFALTERNATEREPRESENTATIVEThisstatutorydeclarationmaybecompletedbytherepresentative,thealternaterepresentative,orthemonitor,asevidenceoftheauthorityofthealternaterepresentativetoactinplaceoftherepresentative.
Thisstatutorydeclarationwouldbecompletedifoneofthecircumstancesinwhichthealternaterepresentativeisauthorizedtoactinplaceoftherepresentativeoccurstoestablishtheauthorityofthealternaterepresentative.
CANADAPROVINCEOFBRITISHCOLUMBIAINTHEMATTEROFtheRepresentationAgreementActre:aRepresentationAgreementmadebynamingasRepresentativenameofAdultnameofRepresentativeTOWIT:NameFullAddressSOLEMNLYDECLARETHAT:a.
Iamthe(strikeoutthedescriptionsthatdonotapply):representativenamedundertherepresentationagreementalternaterepresentativenamedundertherepresentationagreementmonitornamedundertherepresentationagreement.
b.
OneofthecircumstancesreferencedintheRepresentationAgreementinwhichthealternaterepresentativeisauthorizedtoactinplaceoftherepresentativehasoccurred,specifically(describethespecificcircumstanceresultinginthealternaterepresentativehavingauthoritytoact):ANDImakethissolemndeclarationconscientiouslybelievingittobetrueandknowingthatitisofthesameforceandeffectasifmadeunderoath.
DECLAREDBEFOREMEATlocationondateCommissionerfortakingAffidavitsforBritishColumbia(Applystamp,ortypeorlegiblyprintnameofcommissioner)Declarant'sSignatureI,ofSignatureofCommissionerfortakingAffidavitsforBritishColumbia第38页Page38NOTESRESPECTINGTHISREPRESENTATIONAGREEMENTMADEUNDERSECTION7OFTHEREPRESENTATIONAGREEMENTACTThenotesprovidedbelowareforthepurposeofprovidinginformationonly,anddonotconstitutelegaladvice.
Thesenotesarepreparedforthepurposesofthisrepresentationagreementform.
Theyshouldnotbeconsideredacompletedescriptionofmatterstobetakenintoaccountinmakingarepresentationagreement.
Apersonmakingarepresentationagreement,oractingasarepresentative,alternaterepresentativeormonitor,shouldconsulttheRepresentationAgreementActandtheRepresentationAgreementRegulationtoensurethattheyunderstandtheirrightsandduties.
NOTE1:ActionsthatmustbetakentorevokeapreviousRepresentationAgreementTorevokeapreviousrepresentationagreement,youmustalsogivewrittennoticeoftherevocationtoeachrepresentative,eachalternaterepresentative,andanymonitornamedinthatrepresentationagreement.
Revocationiseffectivewhenthisnoticeisgiven,oronalaterdatestatedinthenotice.
NOTE2:Effectofrevocationonaprevioussection7RepresentationAgreementIfyouhavepreviouslymadeasection7representationagreementthatisstilleffective,itwillberevokedbytherevocationprovisioninthisrepresentationagreement.
NOTE3:NamingaRepresentative(a)Thisformprovidesforthenamingofonerepresentativeandonealternaterepresentative.
Ifyouwishtonamemorethanonerepresentativetoactatthesametime,donotusethisform.
(b)TheRepresentationAgreementActsetsoutwhomaybenamedasarepresentative.
Ifanindividualisappointed,thatindividualmustbe19yearsofageorolder,andmustnotbeanindividualwhoprovidespersonalcareorhealthcareservicestotheadultforcompensation,orwhoisanemployeeofafacilityinwhichtheadultresidesandthroughwhichtheadultreceivespersonalcareorhealthcareservices,unlesstheindividualisachild,parentorspouseoftheadult.
(c)ArepresentativemustcompletetheCertificateofRepresentativeorAlternateRepresentativeinForm1undertheRepresentationAgreementRegulation.
Theinformationinthisnotealsoappliesinrespectofanalternaterepresentative.
NOTE4:StatutorydeclarationforevidenceofauthorityofAlternateRepresentativeAstatutorydeclarationthatmaybeusedisincludedwiththisform.
Additionalevidenceestablishingtheauthorityofthealternaterepresentativetoactinplaceoftherepresentativemayberequiredforsomepurposes.
NOTE5:WhataRepresentativemayandmaynotbeauthorizedtodounderasection7RepresentationAgreementUnderasection7representationagreement,arepresentativemaybeauthorizedtohelptheadultmakedecisions,ortomakedecisionsonbehalfoftheadult,aboutallofthefollowingthings:theroutinemanagementoftheadult'sfinancialaffairs,asdescribedintheRepresentationAgreementRegulation;obtaininglegalservicesfortheadultandinstructingcounseltocommenceproceedings,ortocontinue,compromise,defendorsettleanylegalproceedingsontheadult'sbehalf;theadult'spersonalcare,andmajorhealthcareandminorhealthcare,asdefinedintheHealthCare(Consent)andCareFacility(Admission)Act.
Underasection7representationagreement,arepresentativemaynotbeauthorizedtodoanyofthefollowing:tohelptheadultmakedecisions,ortomakedecisionsonbehalfoftheadult,abouttheadult'sfinancialaffairs,otherthantheroutinemanagementoftheadult'sfinancialaffairsasdescribedintheRepresentationAgreementRegulation;tocommencedivorceproceedingsontheadult'sbehalf;tohelpmake,ortomakeontheadult'sbehalf,adecisiontorefusehealthcarenecessarytopreservelife;tohelptheadultmakedecisions,ortomakedecisionsonbehalfoftheadult,aboutthekindsofhealthcareprescribedundersection34(2)(f)oftheHealthCare(Consent)andCareFacility(Admission)Act;despitetheobjectionoftheadult,tophysicallyrestrain,moveormanagetheadult,orauthorizeanotherpersontodothesethings;PAGE1OF2PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011第39页Page39torefuseconsenttothosemattersinrelationtotheMentalHealthActsetoutinsection11oftheRepresentationAgreementAct.
(Pleasenotethatthislistmaynotbecomplete.
)Inaddition,arepresentativemustnotdoeitherofthefollowing:consenttotheprovisionofprofessionalservices,careortreatmenttotheadultforthepurposesofsterilizationfornon-therapeuticpurposes;makeorchangeawillfortheadult.
(Pleasenotethatthislistmaynotbecomplete.
)NOTE6:WhataMonitorisandwhetheroneisrequired(a)Amonitorisapersonresponsibleformakingreasonableeffortstodeterminewhetherarepresentativeiscomplyingwiththerepresentative'sdutiesundertheRepresentationAgreementAct.
(b)Amonitorisrequiredforthisrepresentationagreementiftherepresentationagreementauthorizesarepresentativetomake,orhelpmake,decisionsconcerningroutinemanagementoftheadult'sfinancialaffairs,unlesstherepresentativeistheadult'sspouse,thePublicGuardianandTrustee,atrustcompanyoracreditunion.
(c)AmonitormustcompletetheCertificateofMonitorinForm2undertheRepresentationAgreementRegulation.
NOTE7:Informationforwitnesses(a)Thefollowingpersonsmaynotbeawitness:i.
Apersonnamedintherepresentationagreementasarepresentativeoralternaterepresentative;ii.
Aspouse,childorparentofapersonnamedintherepresentationagreementasarepresentativeoralternaterepresentative;iii.
Anemployeeoragentofapersonnamedintherepresentationagreementasarepresentativeoralternaterepresentative,unlessthepersonnamedasarepresentativeoranalternaterepresentativeisalawyer,amemberingoodstandingoftheSocietyofNotariesPublicofBritishColumbia,thePublicGuardianandTrusteeofBritishColumbia,orafinancialinstitutionauthorizedtocarryontrustbusinessundertheFinancialInstitutionsAct;iv.
Apersonwhoisunder19yearsofage;v.
Apersonwhodoesnotunderstandthetypeofcommunicationusedbytheadultunlessthepersonreceivesinterpretiveassistancetounderstandthattypeofcommunication.
(b)OnlyonewitnessisrequiredifthewitnessisalawyeroramemberingoodstandingoftheSocietyofNotariesPublicofBritishColumbia.
(c)AwitnessmustcompletetheCertificateofWitnessesinForm4undertheRepresentationAgreementRegulation.
(d)Section30oftheRepresentationAgreementActprovidesforanumberofreasonstoobjecttothemakinganduseofarepresentationagreement.
Ifyoubelievethatyouhavegroundstomakeanobjectionatthistime,youmustnotwitnesstherepresentationagreementorexecutetheCertificateofWitnesses,andyoumayreportyourobjectiontothePublicGuardianandTrusteeofBritishColumbia.
NOTE8:WhenaRepresentativemayexerciseauthorityunderthisRepresentationAgreementBeforeapersonmayexercisetheauthorityofarepresentativeunderarepresentationagreement,thatpersonmustsigntherepresentationagreement.
NOTE9:AdditionalformsrequiredforthisRepresentationAgreementtobeeffectiveThefollowingcertificatesmustbecompleted,ifapplicable:Form1(CertificateofRepresentativeorAlternateRepresentative);Form2(CertificateofMonitor),iftheRepresentationAgreementnamesaMonitor;Form3(CertificateofPersonSigningfortheAdult),ifapersonissigningtheRepresentationAgreementonbehalfoftheAdult;Form4(CertificateofWitnesses).
ThesecertificatescanbefoundintheRepresentationAgreementRegulation.
PAGE2OF2PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011第40页Page40Form1-CertificateofRepresentativeorAlternateRepresentativeTobecompletedbyeachrepresentativeandalternaterepresentativenamedinarepresentationagreementmadeundersection7oftheRepresentationAgreementAct[sections5(4)and6(2)].
PartI-Identificationofrepresentativeoralternaterepresentative1.
Thiscertificateappliestotherepresentationagreementmade[date]by[nameofadult].
2.
Iamnamedintherepresentationagreementasrepresentativeoralternaterepresentative.
3.
Mycontactinformationisasfollows:name]telephonenumber],ofaddress],city,province,postalcode],dateofbirth,ifnotatrustcompanyorcreditunion].
Part2-CertificationsmadebyrepresentativeoralternaterepresentativeIcertifythat(a)Iamanadult[doesnotapplytoatrustcompanyorcreditunion],(b)Idonotprovide,forcompensation,personalcareorhealthcareservicestotheadultwhomadetherepresentationagreement,orIdoprovidetheservicesdescribedinthisparagraph,butIamachild,parentorspouseoftheadult,(c)Iamnotanemployeeofafacilityinwhichtheadultwhomadetherepresentationagreementresidesandthroughwhichheorshereceivespersonalcareorhealthcareservices,orIamanemployeedescribedinthisparagraph,butIamachild,parentorspouseoftheadult,(d)Iamnotawitnesstotherepresentationagreement,(e)Ihavereadandunderstand,andagreetoaccept,thedutiesandresponsibilitiesofarepresentativeassetoutinsection16oftheRepresentationAgreementAct,and(f)Ihavereadandunderstandsection30oftheRepresentationAgreementActandhavenoreasontomakeanobjectionasdescribedinthatsection.
signatureofrepresentative,alternaterepresentativeordateauthorizedsignatoryofatrustcompanyorcreditunion第41页Page41Form2-CertificateofMonitorTobecompletedbythepersonnamedasmonitorassetoutinsection12(5)oftheRepresentationAgreementAct.
PartI-Identificationofmonitor1.
Thiscertificateappliestotherepresentationagreementmade[date]by[nameofadult].
2.
Iamnamedintherepresentationagreementasmonitor.
3.
Mycontactinformationisasfollows:name]telephonenumber],ofaddress],city,province,postalcode].
Part2-CertificationsmadebymonitorIcertifythat(a)Iamanadult,(b)Ihavereadandunderstand,andagreetoaccept,thedutiesandresponsibilitiesofamonitorassetoutinsection20oftheRepresentationAgreementAct,and(c)Ihavereadandunderstandsection30oftheRepresentationAgreementActandhavenoreasontomakeanobjectionasdescribedinthatsection.
signatureofmonitordate第42页Page42Form3-CertificateofPersonSigningfortheAdultTobecompletedbythepersonwhosignsarepresentationagreementmadeundersection7oftheRepresentationAgreementAct[section13(4)(d)]fortheadultmakingtheagreement,iftheadultisphysicallyincapableofsigning.
PartI-Identificationofthepersonsigningonbehalfoftheadult1.
Thiscertificateappliestotherepresentationagreementmade[date]by[nameofadult].
2.
Isignedtherepresentationagreementonbehalfoftheadult.
3.
Mycontactinformationisasfollows:name]telephonenumber],ofaddress],city,province,postalcode].
Part2-CertificationsmadebythepersonsigningonbehalfoftheadultIcertifythat(a)Iamanadult[doesnotapplytoatrustcompanyorcreditunion],(b)theadultwhomadetherepresentationagreementwaspresentwhenIsignedtherepresentationagreementonhisorherbehalf,anddirectedmetosignbecauseheorshewasphysicallyincapableofsigning,(c)Iunderstandthetypeofcommunicationusedbytheadultwhomadetherepresentationagreementwhenheorshedirectedmetosigntheagreement,(d)Iamnotnamedintherepresentationagreementasarepresentativeoranalternaterepresentative,and(e)Iamnotawitnesstotherepresentationagreement.
signatureofpersonsigningfortheadultdate第43页Page43Form4-CertificateofWitnessesTobecompletedbyeachpersonwitnessingthesigningofarepresentationagreementmadeundersection7oftheRepresentationAgreementAct[sections13].
PartI-Identificationof,andcertificationsmadeby,firstwitness1.
Thiscertificateappliestotherepresentationagreementmade[date]by[nameofadult].
2.
Iwitnessedthesigningoftherepresentationagreementby,oronbehalfof,theadult.
3.
Mycontactinformationisasfollows:name]telephonenumber],ofaddress],city,province,postalcode].
4.
Icertifythat(a)Iamanadult[doesnotapplytoatrustcompanyorcreditunion],(b)theadultwhomadetherepresentationagreementwaspresentwhenIwitnessedtherepresentationagreement,(c)Iunderstandthetypeofcommunicationusedbytheadultwhomadetherepresentationagreement,orhadinterpretiveassistancetounderstandthattypeofcommunication,(d)Iamnotnamedintherepresentationagreementasarepresentativeoranalternaterepresentative,(e)Iamnotaspouse,child,parent,employeeoragentofapersonnamedintherepresentationagreementasarepresentativeoranalternaterepresentative[doesnotapplytoanemployeeoragentofthePublicGuardianandTrustee,oratrustcompanyorcreditunion],and(f)Ihavereadandunderstandsection30oftheRepresentationAgreementActandhavenoreasontomakeanobjectionasdescribedinthatsection.
signatureofwitnessdate第44页Page44PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIAREPRESENTATIONAGREEMENT(SECTION9)MadeunderSection9oftheRepresentationAgreementAct.
Theuseofthisformisvoluntary.
Beadvisedthatthisformmaynotbeappropriateforusebyallpersons,asitprovidesonlyoneoptionofhowaRepresentationAgreementmaybemade.
Inaddition,itdoesnotconstitutelegaladvice.
Forfurtherinformation,pleaseconsulttheRepresentationAgreementActandRepresentationAgreementRegulationorobtainlegaladvice.
Thisformreflectsthelawatthedateofpublication.
Lawscanchangeovertime.
Beforeusingthisform,youshouldreviewtherelevantlegislationtoensurethattherehavenotbeenanychangestothelegislationorsectionnumbers.
ThenotesreferencedinthisRepresentationAgreementarefoundattheendofthisAgreementandareprovidedforinformationonly.
1.
THISREPRESENTATIONAGREEMENTISMADEBYME,THEADULT:FullLegalNameoftheAdultFullAddressoftheAdult2.
REVOCATIONOFPREVIOUSINSTRUMENTS(SeeNote1–actionsthatmustbetakentorevokeapreviousRepresentationAgreement)(SeeNote2–effectofrevocationonpreviousRepresentationAgreements)Irevokeallofthefollowingmadebyme.
allpreviousRepresentationAgreementsgrantingauthorityundersection7oftheRepresentationAgreementAct;allpreviousRepresentationAgreementsgrantingauthorityundersection9oftheRepresentationAgreementAct.
3.
REPRESENTATIVE(SeeNote3–whomaybenamedasRepresentative)InamethefollowingpersontobemyRepresentative:Date(YYYY/MM/DD)FullLegalNameofRepresentativeFullAddressofRepresentative4.
ALTERNATEREPRESENTATIVE(OPTIONAL)(SeeNote3–whomaybenamedasRepresentative)(StrikeoutthisprovisionifyoudonotwanttoappointanAlternateRepresentative.
)IfmyRepresentativedies,resignsinaccordancewiththeRepresentationAgreementAct,ismyspouse,asdefinedintheRepresentationAgreementAct,atthetimethatImakethisRepresentationAgreement,andourmarriageormarriage-likerelationshipsubsequentlyterminatesassetoutintheRepresentationAgreementAct,orbecomesincapable,thenInamethefollowingpersontobemyAlternateRepresentative:FullLegalNameofAlternateRepresentativeFullAddressofAlternateRepresentativePAGE1OF3我的预先安排护理计划MyAdvanceCarePlan第44页Page44第45页Page45PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIA5.
EVIDENCEOFAUTHORITYOFALTERNATEREPRESENTATIVE(SeeNote4–statutorydeclarationforevidenceofauthorityofAlternateRepresentative)(StrikeoutthisprovisionifyouarenotappointinganAlternateRepresentative.
)Astatutorydeclarationmadebyme,myRepresentative,ormyAlternateRepresentative(ifoneisnamed),declaringthatoneofthecircumstancesreferencedinsection4ofthisRepresentationAgreementhasoccurred,andspecifyingthatcircumstance,issufficientevidenceoftheauthorityofmyAlternateRepresentativetoactinplaceofmyRepresentative.
6.
AUTHORITYOFREPRESENTATIVE(SeeNote5-whataRepresentativemayandmaynotdo)Pursuanttosection9(1)(a)oftheRepresentationAgreementAct,IauthorizemyRepresentativetodoanythingthattheRepresentativeconsidersnecessaryinrelationtomypersonalcareandhealthcare.
7.
INSTRUCTIONSORWISHES(OPTIONAL)(SeeNote6-consultationwithahealthcareprovider)ThefollowingaremyinstructionsorwisheswithrespecttodecisionsthatwillbemadewithintheareasofauthoritygiventomyRepresentativeunderthisRepresentationAgreement:8.
EFFECTIVEDATEThisRepresentationAgreementbecomeseffectiveonthedateitisexecuted.
PAGE2OF3第45页Page45我的预先安排护理计划MyAdvanceCarePlan第46页Page46PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIAPAGE3OF39.
SIGNATURESADULT'SSIGNATURETheAdultmustsignanddateinthepresenceofbothWitnesses.
DateSigned(YYYY/MM/DD)DateSigned(YYYY/MM/DD)SignatureofWitnessNo.
1PrintNameAddressWITNESSESTOADULT'SSIGNATURE(SeeNote7–informationforwitnesses)WITNESSNO.
1WitnessNo.
1mustsigninthepresenceoftheAdultandWitnessNo.
2.
DateSigned(YYYY/MM/DD)SignatureofWitnessNo.
2PrintNameAddressWITNESSNO.
2NotrequiredifWitnessNo.
1isalawyerormemberingoodstandingoftheSocietyofNotariesPublicofBritishColumbia.
WitnessNo.
2mustsigninthepresenceoftheAdultandWitnessNo.
1.
DateSigned(YYYY/MM/DD)SignatureofRepresentativePrintNameREPRESENTATIVEALTERNATEREPRESENTATIVE(StrikeoutifanAlternateRepresentativeisnotappointed.
)DateSigned(YYYY/MM/DD)SignatureofAlternateRepresentativePrintNameADULTANDWITNESSSIGNATURESREPRESENTATIVES'SIGNATURES(SeeNote8-whenaRepresentativemayexerciseauthorityunderthisRepresentationAgreement)IfwitnessisalawyerormemberoftheSocietyofNotariesPublicofBritishColumbia,checkrelevantboxbelow:lawyermemberoftheSocietyofNotariesPublicofBritishColumbiaPrintNameSignatureofAdult我的预先安排护理计划MyAdvanceCarePlan第46页Page46第47页Page47PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011BRITISHCOLUMBIASTATUTORYDECLARATONFOREVIDENCEOFAUTHORITYOFALTERNATEREPRESENTATIVEThisstatutorydeclarationmaybecompletedbytheadult,therepresentative,orthealternaterepresentative,asevidenceoftheauthorityofthealternaterepresentativetoactinplaceoftherepresentative.
Thisstatutorydeclarationwouldbecompletedifoneofthecircumstancesinwhichthealternaterepresentativeisauthorizedtoactinplaceoftherepresentativeoccurstoestablishtheauthorityofthealternaterepresentative.
CANADAPROVINCEOFBRITISHCOLUMBIAINTHEMATTEROFtheRepresentationAgreementActre:aRepresentationAgreementmadebynamingasRepresentativenameofAdultnameofRepresentativeTOWIT:NameFullAddressSOLEMNLYDECLARETHAT:a.
Iamthe(strikeoutthedescriptionsthatdonotapply):adultwhomadetherepresentationagreementrepresentativenamedundertherepresentationagreementalternaterepresentativenamedundertherepresentationagreement.
b.
OneofthecircumstancesreferencedintheRepresentationAgreementinwhichthealternaterepresentativeisauthorizedtoactinplaceoftherepresentativehasoccurred,specifically(describethespecificcircumstanceresultinginthealternaterepresentativehavingauthoritytoact):ANDImakethissolemndeclarationconscientiouslybelievingittobetrueandknowingthatitisofthesameforceandeffectasifmadeunderoath.
DECLAREDBEFOREMEATlocationondateCommissionerfortakingAffidavitsforBritishColumbia(Applystamp,ortypeorlegiblyprintnameofcommissioner)Declarant'sSignatureI,ofSignatureofCommissionerfortakingAffidavitsforBritishColumbia第47页Page47我的预先安排护理计划MyAdvanceCarePlan第48页Page48NOTESRESPECTINGTHISREPRESENTATIONAGREEMENTMADEUNDERSECTION9OFTHEREPRESENTATIONAGREEMENTACTThenotesprovidedbelowareforthepurposeofprovidinginformationonly,anddonotconstitutelegaladvice.
Thesenotesarepreparedforthepurposesofthisrepresentationagreementform.
Theyshouldnotbeconsideredacompletedescriptionofmatterstobetakenintoaccountinmakingarepresentationagreement.
Apersonmakingarepresentationagreement,oractingasarepresentativeoralternaterepresentative,shouldconsulttheRepresentationAgreementActandtheRepresentationAgreementRegulationtoensurethattheyunderstandtheirrightsandduties.
NOTE1:ActionsthatmustbetakentorevokeapreviousRepresentationAgreementTorevokeapreviousrepresentationagreement,youmustalsogivewrittennoticeoftherevocationtoeachrepresentative,eachalternaterepresentative,andanymonitornamedinthatrepresentationagreement.
Revocationiseffectivewhenthisnoticeisgiven,oronalaterdatestatedinthenotice.
NOTE2:EffectofrevocationonpreviousRepresentationAgreementsTherevocationprovisioninthisrepresentationagreementwilldoallofthefollowing:ifyouhavepreviouslymadeasection7representationagreementthatisstilleffective,itwillberevoked;ifyouhavepreviouslymadeasection9representationagreementthatisstilleffective,itwillberevoked.
NOTE3:WhomaybenamedasRepresentative(a)Thisformprovidesforthenamingofonerepresentativeandonealternaterepresentative.
Ifyouwishtonamemorethanonerepresentativetoactatthesametime,donotusethisform.
(b)TheRepresentationAgreementActsetsoutwhomaybenamedasarepresentative.
Ifanindividualisappointed,thatindividualmustbe19yearsofageorolder,andmustnotbeanindividualwhoprovidespersonalcareorhealthcareservicestotheadultforcompensation,orwhoisanemployeeofafacilityinwhichtheadultresidesandthroughwhichtheadultreceivespersonalcareorhealthcareservices,unlesstheindividualisachild,parentorspouseoftheadult.
Theinformationinthisnotealsoappliesinrespectofanalternaterepresentative.
NOTE4:StatutorydeclarationforevidenceofauthorityofAlternateRepresentativeAstatutorydeclarationthatmaybeusedisincludedwiththisform.
Additionalevidenceestablishingtheauthorityofthealternaterepresentativetoactinplaceoftherepresentativemayberequiredforsomepurposes.
NOTE5:WhataRepresentativemayandmaynotdoTheauthorityofarepresentativeappointedunderthisrepresentationagreementincludesthepowertogiveorrefuseconsenttohealthcarenecessarytopreservelife.
Arepresentativeappointedunderthisrepresentationagreementmustnotdoanyofthefollowing:giveorrefuseconsentontheadult'sbehalftoanytypeofhealthcareprescribedundersection34(2)(f)oftheHealthCare(Consent)andCareFacility(Admission)Act;makearrangementsforthetemporarycareandeducationoftheadult'sminorchildren,oranyotherpersonswhoarecaredfororsupportedbytheadult;interferewiththeadult'sreligiouspractices.
(Pleasenotethislistmaynotbecomplete.
)Ifyouwantyourrepresentativetobeauthorizedtodothethingsontheabovelist,youshouldobtainlegaladvice.
Inaddition,undertheRepresentationAgreementAct,arepresentative:maynotbeauthorizedtorefuseconsenttothosemattersinrelationtotheMentalHealthActsetoutinsection11oftheRepresentationAgreementAct;mustnotconsenttotheprovisionofprofessionalservices,careortreatmenttotheadultforthepurposesofsterilizationfornon-therapeuticpurposes;mustnotmakeorchangeawillfortheadult.
(Pleasenotethatthislistmaynotbecomplete.
)PAGE1OF2PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011我的预先安排护理计划MyAdvanceCarePlan第48页Page48第49页Page49NOTE6:ConsultationwithahealthcareproviderIfyouchoosetoincludeinstructionsorwishesinyourrepresentationagreementaboutyourhealthcare,youmaywishtodiscusswithahealthcareprovidertheoptionsandthepossibleimplicationsofyourchoices.
NOTE7:Informationforwitnesses(a)Thefollowingpersonsmaynotbeawitness:i.
Apersonnamedintherepresentationagreementasarepresentativeoralternaterepresentative;ii.
Aspouse,childorparentofapersonnamedintherepresentationagreementasarepresentativeoralternaterepresentative;iii.
Anemployeeoragentofapersonnamedintherepresentationagreementasarepresentativeoralternaterepresentative,unlessthepersonnamedasarepresentativeoralternaterepresentativeisalawyer,amemberingoodstandingoftheSocietyofNotariesPublicofBritishColumbia,orthePublicGuardianandTrusteeofBritishColumbia;iv.
Apersonwhoisunder19yearsofage;v.
Apersonwhodoesnotunderstandthetypeofcommunicationusedbytheadultunlessthepersonreceivesinterpretiveassistancetounderstandthattypeofcommunication.
(b)OnlyonewitnessisrequiredifthewitnessisalawyeroramemberingoodstandingoftheSocietyofNotariesPublicofBritishColumbia.
(c)Section30oftheRepresentationAgreementActprovidesforanumberofreasonstoobjecttothemakinganduseofarepresentationagreement.
Ifyoubelievethatyouhavegroundstomakeanobjectionatthistime,youshouldnotwitnesstherepresentationagreementandyoumayreportyourobjectiontothePublicGuardianandTrusteeofBritishColumbia.
NOTE8:WhenaRepresentativemayexerciseauthorityunderthisRepresentationAgreementBeforeapersonmayexercisetheauthorityofarepresentativeunderarepresentationagreement,thatpersonmustsigntherepresentationagreement.
PAGE2OF2PUBLISHEDBYTHEATTORNEYGENERALOFBRITISHCOLUMBIA,SEPTEMBER2011第49页Page49我的预先安排护理计划MyAdvanceCarePlan第50页Page50ADVANCEDIRECTIVEMadeundertheHealthCare(Consent)andCareFacility(Admission)ActTheuseofthisformisvoluntary.
BeforecompletingthisAdvanceDirective,itisadvisabletoobtainlegaladviceandtheadviceofahealthcareprovideraboutthepossibleimplicationsofthisAdvanceDirective,andyourchoicesaboutthetypesofhealthcareforwhichyoumightgiveorrefuseconsentunderthisAdvanceDirective.
ThenotesreferencedinthisAdvanceDirectivearefoundattheendofthisAdvanceDirectiveandareprovidedforinformationalpurposesonly.
(SeeNote1–limitationsontheeffectofthisAdvanceDirective.
)1.
ThIsIsThEADVANCEDIRECTIVEofThE"ADulT":FullLegalNameoftheAdultFullAddressoftheAdultDateofBirth(YYYY/MM/DD)(OPTIONAL)PersonalHealth(CareCard)Number2.
REVoCATIoNofPREVIousADVANCEDIRECTIVEs:IrevokeallpreviousAdvanceDirectivesmadebyme.
3.
CoNsENTTohEAlThCAREANDREfusAlofCoNsENTTohEAlThCARE:IfIneedhealthcareandIamnotcapableofgivingorrefusingconsenttothehealthcareatthetimethehealthcareisrequired,Igivethefollowinginstructions:[Note:IfahealthcaredecisionisrequiredwhileyouareincapablebutthetypeofhealthcareisnotaddressedinthisAdvanceDirective,thedecisionwillbemadebyasubstitutedecisionmaker.
]Iconsenttothefollowinghealthcare:Irefusetoconsenttothefollowinghealthcare:HLTH39882011/12/21PAGE1OF2Date(YYYY/MM/DD)第51页Page515.
sIgNATuREsADulT'ssIgNATuRETheAdultmustsignanddateinthepresenceofbothWitnesses.
DateSigned(YYYY/MM/DD)DateSigned(YYYY/MM/DD)SignatureofWitnessNo.
1PrintNameAddressHLTH3988PAGE2OF2NoTEsREsPECTINgADVANCEDIRECTIVEsThenotesprovidedbelowareforthepurposesofprovidinginformationonly.
ThesenotesshouldNOTbeconsideredcomplete:apersonmakinganAdvanceDirectiveshouldconsulttheHealthCare(Consent)andCareFacility(Admission)Acttoensurethattheyunderstandtheirrightsandduties.
NoTE1:lImITATIoNsoNThEEffECTofThIsADVANCEDIRECTIVENotethattheeffectofthisAdvanceDirectiveandthegivingandrefusingofconsentunderitissubjecttothelimitationssetoutinsections19.
2(2),19.
3(1)and19.
8oftheHealthCare(Consent)andCareFacility(Admission)Act.
NoTE2:INfoRmATIoNfoRwITNEssEs(a)Thefollowingpersonsmaynotbeawitness:i.
Apersonwhoprovidespersonalcare,healthcareorfinancialservicestotheadultforcompensation,otherthanalawyerornotarypublic;ii.
Aspouse,child,parent,employeeoragentofapersondescribedinparagraph(a);iii.
Apersonwhoisunder19yearsofage;iv.
ApersonwhodoesnotunderstandthetypeofcommunicationusedbytheAdult,unlessthepersonreceivesinterpretiveassistancetounderstandthattypeofcommunication.
(b)Onlyonewitnessisrequiredifthewitnessisalawyerornotarypublic.
(c)YoushouldnotwitnesstheAdvanceDirectiveifyouhavereasontobelievethati.
theAdultisincapableofmaking,changingorrevokinganAdvanceDirective,orii.
fraud,unduepressureorsomeotherformofabuseorneglectwasusedtoinducetheAdulttomaketheAdvanceDirective,ortochangeorrevokeapreviousAdvanceDirective.
wITNEssEsToADulT'ssIgNATuRE-sEENoTE2,INfoRmATIoNfoRwITNEssEswITNEssNo.
1WitnessNo.
1mustsigninthepresenceoftheAdultandWitnessNo.
2.
DateSigned(YYYY/MM/DD)SignatureofWitnessNo.
2PrintNameAddresswITNEssNo.
2NotrequiredifWitnessNo.
1isalawyerornotarypublic.
WitnessNo.
2mustsigninthepresenceoftheAdultandWitnessNo.
1.
4.
ACkNowlEDgmENTsIknowthatasaresultofmakingthisAdvanceDirectivea.
IwillnotbeprovidedwithanyhealthcareforwhichIrefuseconsentinthisAdvanceDirective,andb.
NoonewillbechosentomakedecisionsonmybehalfinrespectofanyhealthcaremattersforwhichIgiveorrefuseconsentinthisAdvanceDirective.
(SeeNote1–limitationsontheeffectofthisAdvanceDirective)第52页Page52资料预先安排护理计划要了解有关预先安排护理计划的更多信息,请访问卑诗长者(SeniorsBC)网站:www.
gov.
bc.
ca/advancecare,卑诗健康连结(HealthLinkBC)网站:www.
healthlinkbc.
ca,查找"advancecareplanning",或拨打电话:8-1-1.
您当地的卫生局:菲沙卫生局(FraserHealth)——www.
fraserhealth.
ca/your_care/advance_care_planning内陆卫生局(InteriorHealth)——www.
interiorhealth.
ca/YourCare/EndOfLife/AdvanceCarePlanning北方卫生局(NorthernHealth)——www.
northernhealth.
ca/YourHealth/AdvanceCarePlanning.
aspx温哥华沿岸卫生局(VancouverCoastalHealth)——www.
vch.
ca/advance_care_planning温哥华岛卫生局(VancouverIslandHealthAuthority)——www.
viha.
ca/advance_care_planning法规要了解有关B.
C.
省没有能力计划法规的信息,请访问司法厅(MinistryofAttorneyGeneral)的网站:www.
ag.
gov.
bc.
ca/incapacity-planning个人计划监护及受托人(PublicGuardianandTrustee)网站:www.
trustee.
bc.
ca/services/adult/personal_planning_tools.
html耐德斯个人规划资源中心(NidusPersonalPlanningResourceCentre)网站:www.
nidus.
ca医疗护理需求如果您需要家庭医生,不列颠哥伦比亚省内外科医生公会(CollegeofPhysiciansandSurgeonsofBritishColumbia)的网站提供可接收新病人的医生名录,网址:www.
cpsbc.
ca/node/216法律需求如果您需要律师,加拿大律师公会不列颠哥伦比亚省分会(CanadianBarAssociationBritishColumbiabranch)提供律师推荐服务.
要了解详情,请访问网站:www.
cba.
org/BC/Initiatives/main/lawyer_referral.
aspx我的全名Myfullnameis紧急联系人Incaseofemergency,call:(姓名/name)(电话/phone)我的医护人员Myhealthcareprovideris我有预先安排护理计划Ihaveanadvancecareplan有代理协议书witharepresentationagreement[第7条sec7第9条sec9]有预先指示书withanadvancedirective我是器官捐献者Iamanorgandonor我重要的文件放在Myimportantpapersarelocated