health care professionals

More than half of us will not have the mental capacity to make our own health care decisions at the end of our life1, yet we rarely have conversations to better prepare for this time or any time when we are unable to make our own health care decisions.

1Ontario Medical Association – Advance Care Planning: Backgrounder OMA’s End-of-Life Care Strategy April 2014

Advance Care Planning versus Health Care Consent

As health care providers, before providing treatment, you must get informed consent from the patient or from their Substitute Decision-Maker (SDM) if the patient is not mentally capable. Advance Care Planning is not consent, but good Advance Care Planning conversations prior to a health crisis can help your patients and their loved ones be better prepared to make informed health care decisions when the time comes.

Studies have shown that Advance Care Planning conversations can improve the quality of care and have a lasting positive impact on the entire family 2,3.

2Detering, KM, Hancock, AD, Reade, MC, and Silvester, W. 2010. The Impact of advance care planning on end of life care in elderly patients: randomized controlled trial. BMJ, 340:c1345

3Heyland, DK, Allan DE, Rocher G, Dodek, P, Pichora D, Gafni A. 2009. Discussing prognosis with patients and their families near the end of life. Impact on satisfaction with end of life care. Open Med, 3(20), 71-80

What is Advance Care Planning in Ontario

Advance Care Planning involves two steps:

Step 1: Deciding who will make future health care decisions for you if you are unable to – this will be your SDM.

Step 2: Discussing with your SDM (and others) your wishes, values and beliefs, and anything else that will help your SDM understand how you would like to be cared for in the event you are mentally incapable of making health care decisions for yourself.

What can I do as a Health Care Provider?

1. Introduce Advance Care Planning to your patients

64% of Waterloo Wellington residents would like to get information about Advance Care Planning from their doctor
Community Survey 2015

Encourage patients to identify their SDM

Ask your patient, who they would want to make health care decisions for them if they were unable to do so? This will be their SDM.

In Ontario there are two ways your patients can identify their SDM:

  1. Confirm their automatic future SDM from the hierarchy (a ranking list in the Health Care Consent Act)  OR
  1. Choosing someone else to act as SDM by preparing a Power of Attorney for Personal Care (a legal document)

Click here for more information about Substitute Decision-Makers.

Encourage your patients to talk with their SDM & loved ones

The best way to be prepared is for patients to discuss with their SDM (and others) their wishes, values and beliefs, and anything else that will help their SDM understand how they would like to be cared for in the event they are mentally incapable of making health care decisions for themselves.

Helpful resources to support your patients

2. Ensure you are getting informed consent from the correct person and that the SDM(s) understands their roles and responsibilities

In Ontario, health care consent must come from the patient or the SDM if the patient is mentally incapable. As health care providers it is imperative that you are getting informed consent from the correct person. Understanding the hierarchy of SDMs is the first step.

When working with SDMs, it is your obligation as a health care provider to explain to an SDM their roles and responsibilities with respect to making decisions on behalf of the mentally incapable patient.

Can anyone act as a Substitute Decision-Maker?

A patient’s SDM is the person or persons in that particular patient’s life who are the highest ranking in the hierarchy and who meet the “requirements” to act as a SDM  as outlined in the Health Care Consent Act (20.2). An SDM may give or refuse consent only if he/she is:

  1. Capable with respect to the treatment
  2. 16 years old, unless he/she is the parent of the incapable person
  3. Not prohibited by a court order or separation agreement from acting as a SDM
  4. Available (in person, by phone, text, email, Skype, etc)
  5. Willing to assume the responsibility of giving or refusing consent

How does a SDM make decisions?

Advance Care Planning conversations about wishes, values, and beliefs should help the SDM make better decisions for the patient when the patient may be mentally incapable. In making health care decisions, an SDM must make decisions the way the person would have made them.

There are two principles for giving or refusing consent on behalf of a mentally incapable person and are outlined in the Health Care Consent Act (21):

  1. If the patient previously expressed wishes that are applicable to the circumstances at hand, the SDM must give or refuse consent in accordance with these wishes
  1. If no prior wishes are known, the SDM must act in the mentally incapable person’s best interests (see section 21.2 in the Health Care Consent Act for a more in-depth description of best interests)

As health care professionals, it is important to know that a SDM is the interpreter of wishes. Living wills and advance directives are not components of health care decision making under Ontario law. These are documents containing wishes that are to be interpreted by SDMs when making a health care decision.

Helpful Resources

Below you will find some resources to help learn more about Advance Care Planning.


Presentations & Webcasts

April 2016, Substitute Decision-Making & Health Care
Presentation slides – Jane Meadus, ACE
Presentation slides– Laurie Borland, OPGT
Presentation slides– Michael Newman, CCB

September 2015 – Education Series with Judith Wahl
Acute Care session – Presentation slides & Webcast
Long Term Care session – Presentation slides
Primary Care session – Judith Wahl’s Presentation slides & WebcastDr. Jeff Myer’s Presentation slides & Webcast