Sample power of attorney for personal care
Province of Ontario—For discussion only
I (Your name) of the (City or Town) of Ontario, revoke any prior power of attorney for personal care, and I appoint (name of your attorney) to be my attorney for personal care in accordance with the Substitute Decisions Act, 1992 (my “attorney”).
(Alternate attorney—delete if not applicable) If my attorney cannot act, or declines to act, as my attorney, or resigns, or dies, or becomes incapable of personal care, or is removed by the court, I substitute * (substitute attorney) to act as my attorney for personal care. (Note: a third party dealing with the substitute will have to be satisfied that the event occurred - there may be a problem about who says that the first attorney is incapable, etc.)
I authorize my attorney, on my behalf, to make any personal care decision for me that I am incapable of making for myself, including the giving or refusing of consent to treatment to which the Health Care Consent Act, 1996 applies (if any restrictions, include here).
(If wanted, include this) I do not want you to use life support systems or to take extreme measures to prolong my life if there is no reasonable possible hope of my recovery. In those circumstances, please allow me to die a natural death with a minimum of pain and anxiety.
Signing part
Signature and addresses of two witnesses
THIS IS A SAMPLE FORM. WE STRONGLY RECOMMEND YOU REVIEW THIS WITH YOUR LAWYER. THERE MAY BE IMPORTANT CONSIDERATIONS OR RESTRICTIONS WHICH SHOULD BE DOCUMENTED.