The FIVE Steps of
Advance Care Planning

Watch the video to learn about the Five Steps

  • Identify
  • Learn
  • Think
  • Talk
  • Include

 Click on the tabs below to learn more about each step 

  • In each step we will check in with Althea, Bob, Tran, Priya, Jacob and Anaya. 
  •  Links in each step will take you to sections of the website with more information on a specific topic.
  •  Return to this page to review all of the Five Steps.


IDENTIFY and decide on your Substitute Decision-Maker(s) - one or more people who are willing and able to speak for you if you cannot speak for yourself.

In Ontario, everyone automatically has an SDM. For most people this is their closest living relative.  We use the SDM Hierarchy from the Health Care Consent Act to determine a person's SDM(s).

After reviewing the SDM Hierarchy, Althea, Bob and Tran identify their automatic SDMs.


Althea is not married and has no children. Her mother is still living and she has two sisters. Her automatic SDM is her mother.

Bob is a widower and has three children. His parents have both died. His children would all share the role of his SDM.

Tran is married. Her automatic SDM is her husband.

Priya is a widow and both her parents have died. She has three daughters. They would be her automatic SDMs and share this role.

Jacob's automatic SDMs would be both of his parents.

Anaya's parents share custody and would share the role of SDM.


They are all going to consider if this is the person who they want in the role of SDM. Visit the SDM section of this website to help identify your SDM.


LEARN about your overall health. This may include any current conditions you want to learn more about. Talk to your healthcare providers about what you might need to prepare for over time.

Bob and Tran have health conditions so ACP will include learning about their condition. For Priya and Jacob, since most or all of their healthcare decisions are made by their SDMs, it is their SDMs who need to learn about the condition. Both Priya and Jacob should be included as much as possible in the discussion so they are given the opportunity to understand. Anaya may be capable of understanding and making some of her own decisions so it is important for her and her SDMs to learn about her condition. If you or the person you are making decisions for have any health conditions, click the button to learn more about this step of the ACP process.



THINK about what is most important to you - about your values, wishes and beliefs.


The most important value to Althea is dignity. When Althea thinks of not having her dignity she pictures being hooked up to machines, not able to speak to her sisters.

The most important value to Bob is independence. When Bob thinks of losing his independence, he pictures what is his brother Jim was like in the intensive care unit.

The most important value to Tran is family. To Tran, she does not need be able interact with her family in any way. Just being present with her family brings her so much joy.

Although Priya may not have capacity to make her own healthcare decisions, she may still be able to express thoughts about what is important to her. Her daughters should also reflect on her values, beliefs and what Priya would consider to be a good quality of life.

Even though Jacob cannot speak, his parents notice that he has non-verbal ways of telling his parents how he feels. They are able to see that he is not as happy being at school and seeing his friends as he used to. 

What is most important to Anaya right now is being able to hang out with her friends and watch movies. She hasn't seen them much throughout her illness. She has continued with her school work and she hopes to be able to go to university when she recovers.



TALK about your values, wishes and beliefs with your Substitute Decision Maker(s), family, friends and health care providers.


See some suggested conversation starters

See the SIX topics to discuss as part of an ACP conversation


INCLUDE your Substitute Decision-Maker(s) in these ongoing conversations whenever possible so they can be prepared to make decisions in the future if they need to.


Learn how your SDM might use your wishes if they have to decide on your behalf