Living Wills: Your Advance Care Plan
Living Wills: Your Advance Care Plan. In the 1970’s society began to take an interest in palliative care and quality of dying which aimed to minimize suffering and promote the dignity of the dying person. People who wanted to have some control about medical intervention at their time of dying began to talk about a “Living Will” which would let their family and their doctors know the level of care they would want if they were not capable of giving consent for treatment at the end of life. In Ontario we use the term “Advance Care Plan” which is a written document provided to one’s physician and to the person who would likely be making decisions for your end-of-life treatment if you were not able to express your wishes. This document may be signed and dated and does not need to be witnessed. You can make changes to the document at any time. The advance care plan does not have any legal status but it is usually respected by medical teams and the family member who is your substitute decision maker. Under the present law, your substitute decision maker cannot authorize medical assistance in dying [MAID] on your behalf, but you can include your wishes about MAID in your advance care plan, to be respected should the law eventually change in Canada. Ontario has an excellent on-line tool to walk you through some of the decisions you might want to write into an advance care plan. HCC ACP GoC Ontario Compliance Toolkit - Speak Up Ontario
Power of Attorney. To be clear, as long as you are capable of consenting to treatment, physicians are obliged to ask your consent to treatment. It is only if the patient is not conscious or too confused to give instructions that the team will turn to the substitution decision maker. In Ontario we have a legal document which can name a Power of Attorney for Personal Care [PoA-C] which gives precedence to that named person to make treatment decisions on your behalf if you are not capable. These forms are free online and require two witnesses for your signature. Powers of Attorney – Publications Ontario (gov.on.ca)
You can also write in your advance care plan in this document, but it is more trouble as you would require two witnesses for your signature to make changes. Medical teams who work with these documents recommend that you not write your advance care plan in the PoA-C document but rather ensure that the person you named to be your PoA-C knows your values and your preferences for care should you be not capable of consent. That person can then make the best decision on your behalf given all the information the medical team has provided and given your family circumstances at the time of crisis. Your PoA-C can also make the decision to transfer you to a supportive living facility if you are not capable of giving consent and do not appreciate the risk of living independently in the community.
Examples. An example I like to use is this: I have told my family that I would never want to be put on a breathing machine, but if I am unconscious in intensive care while waiting for my child to arrive from Europe, I would want to be kept alive long enough for them to get home to say “goodbye” before I passed away. My PoA-C would know to consent to that intervention for temporary treatment. The medical team and the family can later give consent to take me off the machine, i.e., to remove consent to treatment.
Another example would be if I were in an advanced state of dementia, did not recognize my family and contracted pneumonia, my PoA-C could tell the team not to give me antibiotics to treat the pneumonia but rather to keep me comfortable and allow me pass away from that infection. So, if I trust my PoA-C to make decisions about what I would have wanted if I were able to give consent, it is not necessary to be too specific within the PoA-C document itself.
Naming Powers of Attorney. When you write or update your Will, the lawyer will usually ask you to include a Power of Attorney for Property and a Power of Attorney for Personal Care at the same time. This is wise planning and is an opportunity to talk through with your lawyer who would be best placed to make health care decisions or financial decisions if you are not able to do this.
When you are thinking of naming a PoA-C you do not need to name a family member. It can be a friend or relative whom you trust. Sometimes close family members are not in a position to make these difficult decisions or you may feel their values or beliefs are different than yours. The person named in your PoA-C document will have precedence in giving instructions to a medical team over anyone else in your family. However, if you have no named PoA-C there is a hierarchy of family members who will have the right to make decisions on your behalf. These are listed on the website but the first person they would turn to is your spouse. If you have no spouse or the spouse is not capable or refuses to be the PoA-C the medical team would turn to adult children. I there are no adult children they will turn to your parents, then to your siblings, then to cousins or other family members or close friends who step up and say they know you and would be able to express your wishes. If there is absolutely no one who can be identified to make treatment decisions for you the Public Guardian and Trustee will take on this role. Obviously, it is always a good idea to think in advance about who you would want to make a treatment decision for you and to ensure that they know your wishes and values for medical intervention and long-term care if you are not capable of giving consent.
Share you wishes now. There are some good resources online to help you to think about your personal advance care plan. Now is a good time to talk to your spouse and your family about what you would want if you were suddenly taken ill and could not express your treatment wishes.
Beverlee McIntosh, MSW, is a retired medical social worker, a volunteer with Dying with Dignity Ottawa Chapter, and a director on the board of the Funeral Co-operative of Ottawa.