How Will My SDM(s) Make My future Decisions?

  • Your SDM only makes your healthcare decisions when you have been found incapable of making that decision.
  • Your healthcare provider will suggest a treatment plan to your SDM and it will be up to your SDM to decide if they agree (consent) to that treatment or plan. 
  • Your SDM must make the decision that is best for YOU. This is based on YOUR values wishes and beliefs. 

    The law tells SDMs what they need to think about when making decisions for you.

    They must consider:

      1. Your prior capable wishes
      2. Your best interests

How will ACP and my wishes help my SDM in a future goals of care conversation?

  • Healthcare providers will provide information on your current condition and discuss treatment options with your SDM. 
  • Your SDM's role is to determine the option that is best for you. They will think about your wishes and values and tell the healthcare team this as part of a goals of care conversation. 
  • Since you will be incapable of participating at the time, it is important to share information on your values, and what is important to you during the ACP process.

It is important to note that you and your SDM(s) can only consent or refuse consent to a treatment. 

You or your SDM cannot demand a treatment: it is up to the health care provider to determine what treatments will be offered based on your health condition.



How will my values be used to make my healthcare decisions?

  • Making healthcare decisions is about more than just the medical facts.
  •  A person's values and goals are an important part of the process.
  • If you are capable of making your own decisions, you bring your values and goals to the conversation.
  • But once you have lost capacity, it will be your SDM's role to share them with your healthcare providers. 


Your SDM's role:

  • Think about your values, goals and beliefs
  • How do they apply to the decision?
  • Decide if the risk are acceptable 


Healthcare team role:

  • Explain the medical facts about your condition
  • Explain all treatment options
  • Explain all side effects and benefits of the treatment options



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Think about how you might talk with your SDM about your wishes

  • ACP conversations with your SDM are one way you can express these wishes. 
  • Try to imagine what will be the most helpful to them in the future.
  • You cannot predict what kinds of decisions they will have to make. Imagine how your wishes might be used for a variety of situations. 
  • This is why talking about what you can put up with and what you cannot is more helpful than talking about treatments.



Some helpful hints for how to share your wishes:

  • Instead of saying " I don't want a feeding tube" you might tell them "If I am unable to recognize anyone or communicate with people and am dependent for all care, I would not want treatments that would prolong my life" 

  • Saying "no heroics" is often not enough guidance for your SDM in the future. Help them understand what you mean when you say this.  





Wishes can be made just by talking to your SDM(s)

  • You do not need to write these wishes down for them to "count". 
  • In Ontario, wishes can be made by telling your SDM, writing them down, recording in video or any way you choose
  • Your SDM must consider your most recent wishes. It doesn't matter if you wrote them down or not.
  • If you do choose to write things down, talk with your SDM so they understand what you have written.



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How are best interests decided?

  • It will be your SDM's role to decide on your best interests at the time a decision is being made. 
  • They will base this on what they know about you as person and any ACP conversations you may have had.
  • Best interests are used for decision making when here are no prior capable wishes that apply to the situation. Or those wishes are impossible to follow. 
  • An example of an impossible wish might be wanting to get all your care at home. There may come a time when this is not possible for financial reasons or because your family are physically unable to provide the care.




When thinking about best interests, your SDM must consider:

  • Will the treatment or plan:
    • Improve your current condition or well-being? 
    • Prevent worsening of the current condition or well-being? 
    • Slow down the process of getting worse? 
  • Will you get better, worse or stay the same if the treatment or plan is not followed? 
  • Do the benefits outweigh the risks of harm? (**risks/benefits as you would see them) 
  • Is there a less aggressive option that might be as beneficial?



Frequently Asked questions

How will my SDM make decisions if I have not had any ACP conversations?

  • 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

Do I have to write down my wishes for them to "count"?

No. In Ontario, your SDM must consider your most recent capable wishes. It does not matter if they are written down or not. You can tell the person verbally (talking to them), in a video recording, in writing or any way you choose. 

Who Determines Mental Capacity?

  • 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.

What kind of decisions might an SDM make on my behalf?

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

Can an automatic SDM choose not to make my healthcare decisions?

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.

Does my SDM have to follow my wishes?

  • 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.

What if SDM(s) disagree amongst themselves?

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.



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