Advance Care Planning
April 16th is Advance Care Planning Day…a national initiative that encourages people to think about, talk about, and share their wishes for future health and personal care. Meaningful conversations ease stress for loved ones, help healthcare teams provide care that reflects what is important to individuals, and helps to ensure health and personal care choices are heard when it matters most2.
Many people make the mistake of waiting until they have a serious health diagnosis to start thinking about their future health care decisions. It is important to remember that anyone can suddenly find themselves in an emergency where they are unable to speak for themselves, that is why it is never too early to start your ACP.
As healthcare professionals, we talk about the importance of ACP all the time, BUT have you considered who would make decisions for you, and do they know
what is most important to you?
5 Steps1
Identify- Identify who your automatic Substitute Decision Maker (SDM) is and reflect if this is the right person(s) to speak for you if you cannot speak for yourself, and if they are comfortable with the responsibility. In Ontario we use the SDM Hierarchy from the Health Care Consent Act to determine a person’s SDM(s).
Learn- Learn about your overall health. If you have any existing conditions, you may want to talk to your healthcare providers to understand what you may need to consider for your future healthcare.*
Think– Think about what is important to you; your values, beliefs and wishes.
Talk– Talk about your values, beliefs and wishes with your SDM and health care providers.
Include– Include your SDM in these ongoing conversations to prepare them if they need to make decision for you in the future when you cannot make them for yourself.
* If an individual wants to name someone other than the automatic SDM(s) identified in the hierarchy to speak on their behalf, they can complete a Power of Attorney (POA) for Personal Care document to name the individual(s) who have decision-making authority.
When to Revisit Advance Care Planning 1,2
- No SDM identified by the hierarchy
- Change in health status condition
- Decline in functional status
- Admission to the hospital or a new facility
- Has seen a specialist (received new or more information)
- Has a change in their wishes, values, or beliefs
- Is at risk of losing capacity to make decisions
- Death of SDM or no longer able to fulfill the role
Annual Review: A good rule of thumb is to review SDM documents every year to ensure they still reflect the persons wishes2.
Resources
- Advance Care Planning Ontario. (2024). http://www.advancecareplanningontario.ca
- Advance Care Planning Canada. (2024). https://www.advanceacreplanning.ca/
Do not forget https://www.pcdm.ca is available to help healthcare professionals navigate ACP, Goals of Care and Informed Consent.
Download Tip of the Month
PDF – Advance Care Planning
Upcoming Tip
May 2026 – When Care Harms: Moral Distress and the Ethical Call to Self-Care
