Advance Directive for Long-Term Care and Nursing Homes in Newfoundland

Why Admission Is the Critical Moment

When a person transitions into a personal care home or long-term care facility in Newfoundland and Labrador, the clinical team needs to know — immediately — what level of medical intervention the resident wants. Will they be transferred to hospital for acute events? Do they want CPR if their heart stops? Are they open to feeding tubes if they lose the ability to eat independently?

If these questions aren't answered or documented at admission, the team may not have clear direction; in an emergency where no documentation is available, responders may default to full intervention.

Having a completed Advance Health Care Directive (AHCD) with a matching Goals of Care Designation (GCD) before the move makes the admission process smoother and protects the resident's autonomy from day one.

The Documents You Need

Advance Health Care Directive (AHCD)

Your legally executed directive — signed by you, witnessed by two qualifying people, with your Substitute Decision Maker's written acceptance — should be among the first documents you provide to the facility's care coordinator. Ask that it be integrated into the resident's clinical chart so staff can access it when needed.

Goals of Care Designation (GCD)

Your attending physician needs to issue a GCD order before or during the admission process. In a long-term care setting, the GCD is especially important because it guides the nursing staff's response to medical events that happen outside of regular physician hours — which, in a 24/7 care facility, is most of the time.

The three designations — R (Resuscitation), M (Medical Care), C (Comfort Care) — record the planned scope of care. Ask the attending physician how the selected designation applies to interventions such as CPR, hospital transfer, and other treatment in the resident's situation.

Enduring Power of Attorney (EPA)

This is the financial counterpart to the AHCD. The personal care home will need to know who manages the resident's financial affairs — particularly if the resident is no longer managing their own bill payments, banking, or property. Remember that in NL, the EPA covers only financial matters. It has no authority over healthcare decisions.

How Advance Care Planning Works in NL Facilities

The admission conversation

NL Health Services facilities conduct an advance care planning discussion as part of the admission process. The care coordinator or social worker will ask about existing AHCDs, confirm the identity of the SDM, and discuss the resident's goals for care.

If the resident doesn't have an existing AHCD, ask the facility's care team how advance care planning will be handled; don't assume admission itself creates a legally executed directive. A directive created under the stress of an imminent move, often when the resident's cognitive capacity is already declining, is more vulnerable to challenge than one created proactively during a period of stability.

Where the directive is stored in the facility

In a personal care home, submit the AHCD and GCD order for integration into the resident's clinical chart. Ask the care coordinator where exactly these documents are stored and confirm that they are accessible to clinical staff, including overnight and weekend nursing staff. A directive buried on page 47 of a chart is not functionally different from one locked in a drawer at home.

Physician review and GCD updates

In long-term care, review the AHCD at least annually and after any significant change in health — a fall resulting in hospitalization, a new diagnosis, a noticeable cognitive decline, or an acute illness. Ask the attending physician to review the GCD at those points, involving the SDM if the resident no longer has capacity.

Specific Scenarios to Address in Your AHCD

Long-term care raises clinical questions that a general advance directive may not cover:

Hospital transfer. If the resident develops pneumonia or has a stroke, should they be transferred to an acute care hospital? Some residents prefer to remain in their care home and receive treatment there (to the extent the facility can provide it), even if hospital care would be more comprehensive. Others want access to the full range of hospital services.

Emergency resuscitation. In a personal care home, the time between a cardiac arrest and the arrival of paramedics can be significant — longer than in a hospital setting. The clinical reality of CPR outcomes for elderly residents with multiple comorbidities is different from outcomes for younger, healthier patients. Your AHCD should clearly state whether you want CPR attempted.

Feeding interventions. Progressive conditions like dementia often lead to a loss of the ability to swallow safely. Your directive should address whether you want a nasogastric tube, a PEG tube (a feeding tube surgically inserted into the stomach), or whether you prefer comfort feeding — assisted oral intake with the understanding that aspiration is a risk.

Restraint use. Some facilities use physical or chemical restraints when a resident is at risk of falling or exhibits behaviours that pose a safety concern. If you have strong feelings about restraint use, include them in your directive.

Discharge and return home. If your condition improves, do you want to be discharged back to your own home? Or do you consider the facility your permanent residence? This affects planning around property, home maintenance, and financial management.

Remote and Northern Considerations

In Labrador and remote coastal communities, long-term care options are limited. The nearest personal care home may be in Happy Valley-Goose Bay or even St. John's — hundreds of kilometres from the resident's community. Your AHCD should address whether you're willing to be placed in a facility far from home or whether remaining in your community (even with limited formal care) is a priority.

For families coordinating care from a distance, having a clearly documented AHCD and an SDM who can communicate with the facility reduces the logistical burden significantly.

Preparing Before the Move

The Newfoundland and Labrador Advance Directive & Living Will Kit includes long-term care transition checklists, scenario-specific instruction templates for feeding, resuscitation, hospital transfer, and restraint preferences, and the GCD conversation framework — so your advance care plan is in place before admission day, not improvised during it.

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