Advance Directive for Dementia Planning in Manitoba

A dementia diagnosis changes the advance care planning timeline from "eventually" to "now." Under Manitoba's Health Care Directives Act, you can create or update a health care directive as long as you have the capacity to understand treatment information and appreciate its consequences. Once dementia progresses to the point where that capacity is gone, the window closes permanently.

This isn't a theoretical concern. Dementia is progressive, and the line between "has capacity" and "lacks capacity" isn't always obvious. A person in the early stages of Alzheimer's may be fully capable of making and documenting medical decisions. A year or two later, they may not be. There's no predictable schedule for this decline, which is why planning early — ideally at diagnosis or before — matters so much.

What a Dementia-Specific Directive Should Cover

A standard health care directive covers the basics: name a proxy, express general treatment preferences. But dementia creates specific medical scenarios that a generic directive often doesn't address. A strong directive for someone facing cognitive decline should speak directly to these:

Treatment of infections. When a person with advanced dementia develops pneumonia or a urinary tract infection, the question isn't whether treatment exists — it's whether treatment serves the person's goals. Do you want IV antibiotics and hospital transfer? Or do you want comfort care at home or in your personal care home? This is one of the most common treatment decisions proxies face, and it's one of the least commonly addressed in standard directives.

Artificial nutrition and hydration. People with advanced dementia often lose the ability to swallow safely. A directive should specify whether you'd want a feeding tube placed, and under what conditions. Some people draw the line at permanent tube feeding; others want a trial period.

Hospitalization thresholds. Being transferred from a care home to a hospital can be disorienting and distressing for someone with advanced dementia. Your directive can specify that you prefer to be treated in place whenever possible, with hospital transfer reserved for situations where comfort can't be managed otherwise.

CPR and resuscitation. Manitoba's Goals of Care framework uses three levels — Comfort (C), Medical (M), and Resuscitative (R). For many people planning around dementia, Level C or Level M aligns with their values. Specifying your preferred level in the directive helps clinical teams translate your wishes into active medical orders.

Palliative sedation. If you're in pain or extreme distress that can't be managed with standard comfort measures, do you want palliative sedation? This is different from medical assistance in dying (MAID) — it's the use of medication to reduce consciousness in order to relieve suffering at end of life.

Naming the Right Proxy

The proxy decision is particularly important in dementia planning because the proxy will be making decisions over a potentially long period of declining capacity. This isn't a one-time crisis intervention — it's an ongoing role that could span years.

Choose someone who understands your values deeply enough to make decisions for situations your directive doesn't specifically cover. They should be someone who can advocate firmly with medical teams, navigate care home policies, and handle the emotional weight of making end-of-life decisions for someone they care about.

Manitoba defaults to consecutive proxy appointments, meaning the second proxy only steps in if the first can't or won't serve. If you're naming multiple proxies, consider whether you want them to act jointly (deciding together) or consecutively, and state that explicitly in the directive.

Timing: The Capacity Window

Manitoba law presumes capacity — meaning the law assumes you're competent to create a directive unless there's clear evidence otherwise. An early-stage dementia diagnosis does not automatically eliminate your capacity. Many people with mild cognitive impairment or early Alzheimer's retain the ability to understand treatment options and their consequences.

If there's any doubt, ask your physician to document a capacity assessment at the time you sign the directive. This creates a contemporaneous record that can prevent future challenges to the directive's validity.

Don't wait for the "right" moment. The right moment is when you still have capacity. Once it's gone, your family's options narrow to the next-of-kin hierarchy for substitute decision-making — or, in the worst case, a court-ordered committeeship under The Mental Health Act, which can cost $3,000 to $5,000 in legal fees and takes months.

Coordinating with the Care Team

A directive sitting in a drawer doesn't help anyone. Once your directive is complete, distribute copies to your proxy, your family physician, and the personal care home (if applicable). Ask your care team to review your directive during regular appointments so it stays clinically relevant as your condition progresses.

If you're admitted to a personal care home, the facility will typically initiate a Goals of Care conversation as part of the admission process. Having a directive already in place gives that conversation a foundation — your clinical team can align the Goals of Care form with the preferences you've already documented rather than starting from scratch.

Plan While You Can

The Manitoba Advance Directive & Living Will Kit includes a Health Care Directive Worksheet with scenario-specific treatment options that address the medical situations most common in dementia care — infections, nutrition, hospitalization, and resuscitation. It pairs these with Manitoba's Goals of Care framework so your directive speaks the clinical language your care team uses, reducing the risk of misinterpretation when your proxy needs to advocate on your behalf.

Dementia planning isn't morbid — it's practical. The decisions you document today are the ones that protect your autonomy after you can no longer express your wishes yourself.

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