In brief
- Advance care planning can reduce uncertainty and conflict around difficult decisions about end-of-life care when the patient no longer has the capacity to consent.
- As part of routine care, consider discussing with patients the importance of having an advance care plan and appointing a substitute decision maker (SDM).
- Document discussions with your patients about advance care planning, and file any written documents concerning SDMs and the patient’s wishes in the medical record.
Treatment decisions for end-of-life care can be challenging, particularly when the patient is incapable of consenting and their wishes are unknown or unclear. This lack of clarity can lead to disagreements and conflict between family members and within healthcare teams. Advance care planning (ACP) can reduce these challenges and help improve the overall end-of-life experience for patients and their families.
ACP is a process that includes the patient choosing a substitute decision-maker (SDM) and communicating their wishes, values, and beliefs to others. The goal of such planning is to ensure that others understand the patient’s preferences for healthcare in the event they are unable to provide consent.
ACP is not a replacement for consent. While ACP can help guide decision-making, consent is still required for specific treatments. That consent may come from the patient if they are capable, from an incapable patient’s SDM, or through an advance care directive, where permitted. It’s important to note that currently ACP cannot include consent to medical assistance in dying, either through an SDM or an advance directive.1
Case study: A patient would like a friend involved in their care
Your patient is 70 years old, single, and in generally good health. They tell you they have not shared their end-of-life wishes with anyone, including an adult child who lives far away.
Your patient has a close relationship with a friend who lives nearby. They tell you they would like this friend to be involved in decision-making when they no longer have the capacity to consent to treatment.
In response, you could proactively discuss with your patient the importance of doing an advance care plan specifying their care preferences should they become incapable of giving consent to treatment. This may include making legal arrangements to appoint someone—such as the close friend—who they feel will best respect their treatment goals. You could also tell the patient that, without such a document, their adult child would likely be appointed substitute decision-maker, in keeping with legislation.
Advance care planning ≠ Advance directive
Advance care planning is not the same as an advance directive. Advance directives often include explicit instructions to consent or withhold consent to treatment in specific circumstances. They may also serve to formally assign a substitute decision-maker in the event the patient becomes incapacitated. In many provinces and territories, advance directives come into effect when the patient is incapacitated or otherwise unable to communicate their wishes.
Identifying substitute decision-makers
When a patient loses the capacity to consent, physicians need to turn to the appropriate person to obtain consent for end-of-life treatment. An SDM is an individual who has the legal authority to make decisions on behalf of the patient. This authority may be granted through a legal document, such as an advance directive, by legislation, or by the courts. If a physician incorrectly makes an assumption about who is authorized to make decisions on the patient’s behalf, it can lead to hospital or College complaints and potentially expose the physician to civil legal actions.
Generally speaking, SDMs must comply with any wishes of the patient expressed orally or in writing when they were capable of making decisions. The SDM should be guided by the patient’s best interests, and ideally there will have been a prior conversation between the patient and SDM about the patient’s wishes. The patient may also identify other people who can support the SDM through the decision-making process, or who should not be involved in care decisions.
Discussing ACP with patients
Discussing ACP early and respectfully with patients and, with patient consent, their families, can help promote person-centred care and assist in ensuring SDMs follow through on the patient’s end-of-life wishes.
Introducing ACP as part of routine care in a physician-patient relationship can help normalize these conversations. Ideally, discussions about ACP should be ongoing and revisited with the patient as their medical condition evolves or significant life events occur.
Here are some tips to help get started:
- Obtain available tools to guide discussions about ACP. Advance Care Planning Canada has helpful resources for patients and healthcare professionals.
- Initiate discussions about ACP sensitively. You may need to introduce the subject over the course of multiple visits.
- Strive to inform your patient’s decisions about end-of-life care. Provide information about potential symptoms associated with end-of-life conditions. Discuss your patient’s preferences or concerns about specific treatments, such as resuscitation and intubation, so that any misunderstandings by the patient are corrected and apprehensions are mitigated.
- Encourage patients to document and share their care plan with loved ones, their SDMs, and other healthcare providers.
Resources
Many provincial governments, regional health authorities, and medical associations or federations offer online resources to help with ACP. Familiarize yourself with resources in your jurisdiction, many of which are listed by Advance Care Planning Canada, as well as relevant policies:
Additional reading
Note
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As of June 7, 2025 (or potentially earlier), provisions in Québec’s end-of-life legislation permitting advance requests for MAID will come into force. Although the legislation in Québec may allow advance requests for MAID as of that date, it will remain illegal to carry out MAID until the Criminal Code of Canada is also amended.
