Advance Directive: How it works and why you should have one

No one lives forever.

Before our inevitable demise, many of us will face a period of mental or physical incapacity. As unpleasant as this is to consider, it’s wise to do so while you are healthy. Incapacity can come in many forms, ranging from dementia, severe depression, coma or heavy sedation from pain medication. 

In the event of incapacity, it’s important to have documents in place that allow someone (of your choosing) to act as your substitute decision maker.

In Ontario, the legal document granting someone this authority is called a power of attorney for personal care. A downside with this vital document is that it’s often too generic, limiting its usefulness.  For example, we only rarely see one include detailed instructions on the type of care and living accommodations desired (or to be avoided), should you face a period of incapacity.

Your substitute decision maker may be responsible for decisions relating to:

• Palliative care
  • When to start palliative care
  • What type of palliative care to authorize
  • Where care should be provided (at home, in a hospice or in hospital)
• A blood transfusion
• Authorizing CPR
• Breathing support through a ventilator
• Feeding tubes
• Medication administration
• Organ donation
• Hiring additional private care to supplement hospital/hospice services.

A lack of direction on your care preferences places your substitute decision maker in the difficult position of making decisions on your behalf that may not align with your wishes.

If your existing power of attorney for personal care is light on care instructions, there’s an excellent solution to bridge this gap called an advance directive.

An advance directive is a document that outlines your preferences for future health care. It informs your substitute decision maker as to the type of care you’d like. By making your wishes clear, you can significantly reduce guilt, stress and even conflict for your loved ones. An advance directive also guides health care providers in deciding on your treatment plan.

The terminology for this document varies across Canada. In Ontario, it’s called an Advance Care Directive. 

An excellent resource for advance directives is Dying with Dignity’s Advanced Care Planning Kit.  Their free booklet walks you through thought-provoking exercises to help you decide and document what care you’d like during a period of incapacity. Many of these questions focus on preferences for end-of-life care. 

In their own words, “Advance Care Planning is a process where you:

• Think about your values, beliefs, and preferences for your future health care.
• Write down (or “document”) your directions in an Advance Directive.
• Share these directions with a Substitute Decision-Maker that you choose.”

Their website includes templates for advance directives for various provinces and territories.

It’s important to understand that by completing an advance directive, depending on how it’s structured, you may override your existing power of attorney for personal care.

Rather than completing this template independently, the safest option is to work with your lawyer to complete this document. This will ensure that your advance directive properly complements (or suitably replaces) your existing power of attorney for personal care.

If you’d rather not complete a formal document, simply writing down your preferences regarding future health care will help guide your substitute decision maker. For instance, you could complete the advanced care planning kit or outline your wishes in a typed or handwritten document.

The next step is to share this document with your substitute decision maker so they’re aware of its existence and understand your wishes. This also provides them with the opportunity to ask questions about these wishes.

Whatever option you choose, keep the document somewhere accessible. Ideally, file it with your original power of attorney for personal care so that it can be easily located if it needs to be referenced.

It’s worth highlighting that this isn’t a document you should set and forget. As you age face new health concerns, your health care preferences will inevitably change. For instance, incontinence may feel like an unacceptable quality of life for a young adult. However, many older adults experience and become comfortable with the realities of incontinence. 

If someone has named you as their power of attorney for personal care, you should ask where this document is filed and ask to see a copy. If their power of attorney for personal care is light on instructions, consider broaching the topic of advance directives (or sharing this post) to initiate discussions around their wishes, should you need to step into this role in the future. Though it can be hard to initiate these conversations, doing so will save you a lot of stress and uncertainty down the road.