• Advance Care Planning (ACP) is a way for a person and/or their SDM to prepare for future health care needs.
• It is a series of conversations.
• ACP is NOT consent for any treatments that are in the future.

• ACP is a way to help you prepare for your future health care needs
  • Learning about your illnesses
  • Identifying your substitute decision-maker
  • Thinking about your priorities and values about your health
• ACP helps your substitute decision-maker learn more about your health issues, values and priorities in case they need to make decisions for you in the future
• ACP prepares your SDM(s) to give consent for treatments in the future if you are NOT mentally capable.
• ACP conversations you have today will make it easier for your SDM(s) in the future so they don’t have to guess at your wishes in the middle of a difficult time.
• ACP can decrease the burden and stress experienced by your SDM

• Everyone in Ontario automatically has an SDM
• If there are no relatives or appointed SDMs, the Public Guardian and Trustee (PGT) will act as SDM if someone is not capable of making healthcare decisions.
• A person can choose to have ACP conversations with their healthcare providers, to share their values and wishes.
• Healthcare provider can share this information with the PGT if they have to make healthcare decisions 

• If your wishes are not known, your SDM(s) must act in your “best interests.”
• “Best interests” has a specific meaning in law: your SDM must consider a person's values and beliefs.
• They would also consider:
  • Your health condition
  • If you are likely to improve, remain the same or deteriorate without the treatment
  • The risks and benefits of the treatment options

• It is good idea to involve your SDM as much as possible in these conversations.
• ACP is meant to prepare your SDM to make your healthcare decisions in the future if you loses capacity to make your own decisions.
• If you are not comfortable including your SDM in ACP conversations, think if there is  someone else you would prefer in the role.
• Your SDM may have to make some hard choices. Knowing about the person and their values can make this easier. 

• Advance Care Planning is a process and a person can always change their mind.
• In Ontario, it is the most recent wishes that your SDM(s) should consider when they make a decision.
• Things you tell an SDM are just as important as what you put in writing. The most recent is the one that's important. 
• For example if you write down something today and then tell your SDM something different in a month, those are the wishes they need to consider.
  

• Informed consent refers to the permission you give health care providers for medical investigations and/or treatments.
• Before you can be asked to give permission, a healthcare provider must give you all the information you need to make that decision.
• They must also give you an opportunity to ask questions. 
• If English is not your first language, you may ask for an interpreter.
• It is your health and you have a right to ask information you need.

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• The health care provider proposing the treatment will determine if you are mentally capable of consenting to or refusing treatment.
• For example, if you are having surgery, it will be your surgeon who determines if you are capable of agreeing to the surgery.
• If you are found incapable, you have the right to ask the Consent and Capacity Board to review that finding. The health care provider who believes you are mentally incapable must tell you about that right of review.

A capacity evaluator is any regulated healthcare practitioner who is a member of:

(a) the College of Audiologists and Speech-Language Pathologists of Ontario,

(b) the College of Dieticians of Ontario,

(c) the College of Nurses of Ontario,

(d) the College of Occupational Therapists of Ontario,

(e) the College of Physicians and Surgeons of Ontario,

(f) the College of Physiotherapists of Ontario,

(g) the College of Psychologists of Ontario, or

(h) the Ontario College of Social Workers and Social Service Workers who hold certificate of registration for social work

A capacity assessor is someone who, in addition to being a regulated healthcare practitioner, has completed additional training and holds professional liability insurance of not less than 1,000,000.00 specifically for capacity assessments.

If you cannot speak for yourself, your SDM(s) will make decisions for your care. These decisions will be based on the conversations you already had about your wishes, values and beliefs. These decisions could include things like whether or not to:

• have tests, surgery or other medical care
• stop or start a treatment
• move to a long-term care home

Yes. Any SDM can choose not to make your healthcare decision. If this happens, your healthcare provider will ask the next person lower down on the hierarchy list to make your healthcare decision.

• Your SDM must look at any wishes you made when you were  mentally capable.

• Your SDM must ask themselves two questions:

1) Do they apply to the current decision?

2) Are they possible to follow?

• SDMs do not have to follow a wish that is impossible to honour.
• There are many things that can make a wish impossible to honour. Decisions will depend on the person's health and care needs, finances and the number of people around who can help care for a person.
• For example, a person may tell an SDM that they wish to remain at home but there may be times when a hospital or long-term care is the best place to receive care based on the person's needs.

• If you are not happy with your automatic SDM, you may appoint an Attorney for Personal Care.
• You must be capable at the time you appoint an Attorney for Personal Care.
  

• Looking at the list of people who can make decisions, a person may have more than one person at the same level (e.g children or siblings)
  



• If they are highest on the list, they would automatically make decisions. They must make decisions together (jointly) or decide among themselves which one will act as your SDM.

• For example, if a person has three children (#5 on the list), all three are entitled to act as SDM(s). They must act jointly and agree on any decisions for a person's health care or they can agree that only one of them will make decisions. The health professionals cannot pick which one of the three should make decisions. The three children must decide among themselves whether they will all act together or if only one of them will.

An Attorney for Personal Care (POAPC) is one type of SDM. They are the second highest on the list of SDMs.

• A Power of Attorney for Personal Care ONLY gives the person the ability to make decisions about healthcare. They cannot make decisions about your property or finances.
• For property and finances, a person must prepare a Power of Attorney for Property.
• A person does not need to choose the same person for both. Each is appointed in a separate document.
•  For more information:
  • Advocacy Centre for the Elderly
  • Attorney General of Ontario
  • Community Legal Education Ontario
    
    

If people who are equally entitled to act as SDM(s) cannot agree on the decisions about your treatment, you may have several options depending on your clinical setting:

• Make sure you have explored the underlying illness understanding and underlying reasons behind the disagreement as there may misunderstandings that are leading to the issue.
• If you have access to bioethics consultation, they may be able to support the SDM(s) to reach consensus.
• If you cannot reach agreement among the SDM(s), the Public Guardian and Trustee is required to act as SDM. The Public Guardian and Trustee does not choose between the disagreeing decision-makers but makes the decision instead.