Imagine: You’re in the hospital, too ill or hurt to speak for yourself…
Think: Do you know who would make health care decisions for you?
Imagine: Your husband / wife has had a stroke and is unable to communicate with doctors…
Think: Do you know what kind of health care he / she would want or not want?
Unfortunately, these situations occur more often than we would like to admit. Deciding who will make health care decisions for you and having conversations with them can make it easier down the road.
Below you will find information on how to decide who will make health care decisions for you (your Substitute Decision-Maker or SDM) as well as the roles and responsibilities this person(s) will play, if needed.
Putting it into Context
Under Ontario law, before health care is provided to you, your health care practitioner must get informed consent. Consent must come from you or from your SDM, if you are mentally incapable.
We all hope to be able to make our own health care decisions until the end; however, over half of us will need someone to make health care decisions for us at the end-of-life.1
Advance Care Planning can help prepare you and your SDM in the event that your SDM needs to make health care decisions on your behalf.
Studies have shown Advance Care Planning can improve your quality of care and have a lasting impact on the entire family.2
1 Ontario Medical Association – Advance Care Planning: backgrounder OMA’s End-of-Life Strategy April 2014
2 Detering, 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
How can I do Advance Care Planning for myself?
Advance Care Planning can help you and your loved ones prepare for a time when you are mentally incapable of making your own health care decisions. Follow the two steps below and start Advance Care Planning conversations today.
Step 1: Identify your SDM
Ask yourself who you would want to make health care decisions on your behalf if you were unable to do so? This will be your SDM.
In Ontario there are two ways to identify your SDM:
- Confirm your automatic future SDM from the hierarchy (a ranking list in the Health Care Consent Act) OR
- Choosing someone else to act as SDM by preparing a Power of Attorney for Personal Care (a legal document)
While deciding who you want as your SDM consider the following questions:
- Do you trust this person to make decisions the way you want them to be made even if they do not agree with your choices?
- Will this person be open to having conversations about your wishes, values and beliefs as they relate to health and end-of-life care?
- Is this person able to make decisions under stress?
Video used with permission from Speak Up.
Step 2: Talk with your SDM & Others
The best way to be prepared is to discuss 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 if I am someone’s SDM?
Knowing if you’re someone’s SDM is the first step. To do this we encourage you to:
- Look at the hierarchy and see if you are automatically in the role of substitute decision-maker for someone
- Ask your family members if they have ever done a Power of Attorney for Personal Care that named you as a SDM
SDMs play a very important role. The essential component of being a SDM is to be an informed one. To do this, ask yourself “What information do I need to know to be more comfortable acting as a SDM?”
To help you become informed we encourage you to understand your roles and responsibilities as a SDM as well as the types of decisions you may be asked to make by reviewing the information below.
What do SDMs do?
A SDM will be asked to make health care decisions for a loved one if he/she is mentally incapable of making the decisions for themselves.
What types of decisions may they be asked to make?
- Long-term care placement
- Health care decisions
- Consent or refuse tests, procedures, surgery
- Begin or withdraw life-prolonging measures
- Who will provide medical care
- Speaking with health care professionals
- Admit or discharge from medical facility
- Looking at medical information
- Personal care decisions
How does a SDM make decisions?
SDMs must make health care decisions the way the person would have made them if they were capable. 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):
- 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
- 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)
Note: A Living Will is a commonly used term in Canada. A living will is an expression of your wishes – not directions to healthcare practitioners. If you do have a living will please be sure to give it to your SDM so they can refer to it when making health care decisions for you.
Can anyone act as a SDM?
According to the Health Care Consent Act (20.2) there are certain requirements that a SDM must meet in order to act on your behalf. A SDM may give or refuse consent only if he/she is:
- Capable with respect to the treatment
- 16 years old, unless he/she is the parent of the incapable person
- Not prohibited by a court order or separation agreement from acting as a SDM
- Willing to assume the responsibility of giving or refusing consent
Video used with permission from Speak Up.
What does Mentally Incapable mean?
In order for your SDM to step in and make health care decisions for you, you need to be deemed mentally incapable of making that particular treatment decision. The core components of capacity, as defined in the Health Care Consent Act are:
1) Ability to understand the information that is relevant to making a decision about the treatment, admission, or personal assistance service
2) Ability to appreciate the reasonable foreseeable consequences of a decision or lack
For treatment decisions, the health care provider proposing the treatment will determine if you are mentally capable of giving informed consent. If he/she believes you are mentally incapable, they will then turn to your SDM.
We encourage you to decide who will be your SDM if you ever become mentally incapable of making your own health care decisions. Once you have decided who this will be, have conversations with them about your wishes, values, believes and what’s important to you.
These are conversations worth having now… don’t wait for a crisis.
Below you will find some resources to help you learn more about Advance Care Planning.
Health Care Consent Act, 1996
Substitute Decisions Act, 1992
Tip Sheet #1 – Advance Care Planning & Health Care Consent Basics
Tip Sheet #2 – Hierarchy of Substitute Decision-Makers
Substitute Decision-Making Brochure – eTHel
Power of Attorney Kit
Presentation slides – Public Education Session September 2015 Judith Wahl