Advance Care Planning Ontario: The Five-Stage Process for Families

Advance Care Planning Is a Process, Not a Form

Speak Up Ontario, the provincial advance care planning program run by Hospice Palliative Care Ontario, defines advance care planning as an ongoing process of reflection, discussion, and documentation. It is not a one-time form you fill out and file away. The reason this distinction matters is that Ontario's Health Care Consent Act does not recognize a standalone written directive as binding medical instruction — it requires a living person to provide consent at the bedside. Your advance care plan is only as strong as the person interpreting it and the clarity of the wishes you documented.

Stage 1: Identify Your Current Default SDM

Before you create any documents, find out who the law currently assigns as your substitute decision-maker. Under section 20 of the HCCA, the hierarchy starts with a court-appointed guardian (if one exists), then any attorney named in a Power of Attorney for Personal Care, then a Consent and Capacity Board representative, then your spouse, then your children and parents (equally ranked), then siblings, then other relatives, and finally the Office of the Public Guardian and Trustee.

If you have not signed a POA-PC, your default SDM is probably your spouse. If you are unmarried, it may be your parents or your adult children — and if multiple people share the same tier, they must act unanimously. Knowing who currently holds this authority tells you whether the default is acceptable or whether you need to override it by executing a POA-PC.

Stage 2: Choose Your Attorney and Have the Conversation

If the default hierarchy does not match your preferences — or if you want to prevent a sibling deadlock — you need to appoint an attorney through a POA-PC. Choose someone who will follow your wishes even when other family members disagree, who is emotionally equipped to make high-stakes medical decisions under pressure, and who is geographically accessible enough to reach the hospital within a reasonable timeframe.

Then have the conversation. Not a vague "you know what I want" talk, but a specific discussion about scenarios: What if you have a severe stroke with partial recovery potential? What if you develop late-stage dementia and can no longer recognize your family? What if a temporary ventilator could save your life but quality of life afterward is uncertain? Your attorney needs to understand not just your preferences but the values and reasoning behind them, because they will face situations you did not specifically anticipate.

Stage 3: Document Your Treatment Preferences

Write down what you discussed. The POA-PC can include detailed instructions about your healthcare preferences, and specificity is what separates instructions that physicians respect from instructions they set aside as vague.

Address each major treatment category: cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition and hydration, antibiotics for life-threatening infections, dialysis, blood transfusions, and palliative sedation. For each one, distinguish between reversible conditions (where the treatment is a bridge to recovery) and irreversible or terminal conditions (where it prolongs the dying process without meaningful improvement).

Include your values statement: what makes life meaningful to you, what level of cognitive function you consider acceptable, and what you would define as "living" versus "merely existing." This gives your attorney a framework for the decisions your specific instructions do not cover.

Stage 4: Execute the Documents

You need two separate documents, both executed under the Substitute Decisions Act:

The Power of Attorney for Personal Care covers healthcare and personal care decisions. Your treatment preferences go here. Both this and the Continuing Power of Attorney for Property require two adult witnesses who are not your spouse, children, the appointed attorney, or the attorney's spouse.

The Continuing Power of Attorney for Property covers financial decisions during incapacity. Without it, your family may face a year-long guardianship application costing $10,000 to $15,000.

If you are signing remotely, the SDA's permanent virtual signing provisions require that at least one witness be a licensee of the Law Society of Ontario. All parties sign counterpart copies simultaneously during a video call.

Stage 5: Coordinate Emergency and Clinical Orders

A completed POA-PC with treatment instructions is not visible to paramedics responding to a 911 call. First responders in Ontario follow only the DNR Confirmation Form (Form 014-4519-45), which must be signed by a physician and posted visibly in the home.

If a planned home death is appropriate, discuss the Expected Death in the Home (EDITH) protocol with the palliative care team. EDITH authorizes home care nurses to pronounce death and avoids emergency services being dispatched.

These clinical arrangements require advance coordination with your medical team and cannot be set up independently. The earlier you start the conversation, the more likely the logistics will be in place when they are needed.

Keeping the Plan Current

Advance care planning is not a single event. The Speak Up Ontario program recommends revisiting your plan whenever your health status changes significantly — a new diagnosis, a hospitalization, a change in functional capacity. Under the SDA, executing a new POA-PC automatically revokes all previous ones unless the new document explicitly states otherwise. Prior capable wishes can be updated verbally at any time; the most recent wish always takes legal precedence.

Our Ontario Advance Directive & Living Will Kit walks through all five stages with treatment preference worksheets, attorney conversation scripts, witnessing checklists, and the DNR-C/EDITH coordination protocol — everything needed to complete the process without a lawyer.

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