Caregiver Resources - Advance Care Planning

An advance care plan is a written document which sets out a person’s wishes with regards to personal care and medical treatment. This document may include the person’s beliefs, values, and goals and will inform a substitute decision maker with respect to care decisions. The advance care plan can also be shared with health professionals; however, it is not a substitute for consent to treatment or personal care. Advance care planning is a process; through reflection and communication a plan is developed.  In addition to the individual, advance care planning can involve family members, health professionals and financial or legal advisors, lawyers, or powers of attorney.

Why is it important?

  • Health care decision are becoming increasingly complex; advances in medical technology mean that people with complex conditions live longer, resulting in 73% of Canadians dying from chronic disease- this translates into a large proportion of Canadians who cannot make their own decisions near death
  • Patients who have end-of-life conversations with their doctors/family members are much more likely to be satisfied with care received, require fewer aggressive interventions at end of life, more likely to take advantage of hospice resources, place less strain on caregivers
  • End-of-life discussions and advance care planning can reduce moral distress for healthcare providers; affect outcomes such as completion of advance directives or powers of attorney for personal care; improve adherence to individual’s wishes

Common Causes

  • Concern over the future of one’s health and possible treatment (initiation, continuation, discontinuation) or care options

Key Considerations

  • Think about what’s right for you: reflect on values, beliefs,  your current understanding of medical procedures and what you need to know more about to be fully informed, situations experienced with others and how you felt, how you would feel if you were to pass away at home vs. hospital or a hospice, if you would want certain medical procedures such as feeding tubes,  end-of-life expectations (e.g. being in pain),  meaningful considerations (e.g. having friends/family nearby, music playing)
  • Learn about end-of-life options and medical procedures: discuss the different possibilities and options with your health care provider (3)
  • Think about who will make medical decisions on your behalf if you become incapable: this may be a spouse, a trusted family member or close friend
  • Have the conversation: discuss your values, wishes, and goals with your substitute decision maker, health professionals involved in your care, family members, lawyer or financial or legal professional, ask your health professional for any clarifications regarding medical treatment
  • Write down and record your wishes: document any changes and review your plan regularly and make your choices clear to others
  • Give your substitute decision maker the power to act: inform the chosen individual and complete the Power of Attorney for Personal Care