Do Not Resuscitate Quebec: DNR Orders, Goals of Care, and Niveaux de Soins

Quebec Doesn't Use Standard DNR Forms

If you've searched for a "DNR form" or "do not resuscitate order" in Quebec, you've probably come up empty. That's because Quebec's healthcare system doesn't use the standalone DNR forms common in other provinces and the United States.

Instead, Quebec uses a standardized clinical tool called the niveaux de soins (levels of care) — sometimes referred to as niveaux d'intervention médicale (NIM) or objectifs de soins (goals of care). This system replaces the binary yes/no of a DNR order with a graduated scale of treatment intensity that physicians and patients establish together during clinical conversations.

The Four Levels of Care

The niveaux de soins system uses four levels, each representing a different treatment philosophy:

Level A — Prolong life by all means. Full medical intervention including CPR, intensive care unit transfers, mechanical ventilation, and all available life-sustaining treatments. This is the default level when no discussion has occurred.

Level B — Prolong life through limited care. Therapeutic treatments to correct health deterioration, but transfers to intensive care may be restricted. Some life-sustaining measures are used, but within defined boundaries. The patient and physician agree on which specific interventions are and aren't appropriate.

Level C — Prioritize comfort over life-prolonging care. Treatment focuses on symptom relief and maintaining quality of life. Reversible conditions (like an infection) may still be treated, but the overall goal shifts from extending life to managing comfort. CPR is typically not performed at this level.

Level D — Ensure comfort without prolonging life. Strictly palliative care. All treatment focuses on pain management, comfort, and dignity. No life-prolonging interventions. This is the closest equivalent to what other jurisdictions accomplish with a DNR combined with a comfort-care order.

How the Goals of Care Discussion Works

The niveaux de soins form isn't something you fill out at home. It's a clinical document that emerges from a conversation between a physician (or IPS — a specialized nurse practitioner) and the patient or their mandatary.

When it happens: Typically at hospital admission, upon entering a CHSLD (long-term care facility), during a significant change in medical condition, or as part of advance care planning discussions with your family doctor.

Who participates: The patient, if they have capacity. If the patient is incapacitated, their homologated mandatary makes decisions. If there's no mandatary, the statutory consent hierarchy (spouse, close relatives) applies.

What you discuss: The physician explains the patient's current condition and prognosis, the realistic outcomes of each intervention level, and the expected success rates of procedures like CPR. For example, a physician might explain that for a patient with advanced heart failure, the likelihood of CPR resulting in survival to hospital discharge is under 5% — context that transforms the decision from abstract to concrete.

The form itself: The physician records the agreed-upon level on a standardized provincial form, which is signed, placed in the patient's medical file, and shared with the clinical team. It travels with the patient if they're transferred between facilities.

How Niveaux de Soins Interact With Your DMA

Your DMA and the niveaux de soins form occupy overlapping but distinct territory.

The DMA records your advance decisions about CPR and four other specific treatments, registered before a crisis with RAMQ. The niveaux de soins form records a clinical discussion that happens in a medical setting, usually in response to a current health situation.

When both exist, the DMA takes legal precedence for the five treatments it covers. If your registered DMA refuses CPR, the medical team must honour that even if a niveaux de soins form completed by your mandatary at hospital admission selected Level A (full intervention).

But the niveaux de soins form covers much more than the DMA does — it addresses surgical interventions, antibiotic use, blood transfusions, transfer decisions, and overall treatment philosophy. For everything outside the DMA's five treatments, the goals-of-care discussion fills the gap.

Questions to Ask During the Goals of Care Conversation

Going into this conversation prepared makes a significant difference. Consider asking:

• "Given the current diagnosis, what is the realistic success rate of CPR?" Success rates vary dramatically — from 25% for a young person with an acute event to under 2% for a frail elderly patient in a CHSLD.

• "How does this level of care align with my registered DMA?" If you've registered advance medical directives, the physician should verify that the niveaux de soins selection doesn't conflict with your documented treatment decisions.

• "Are there specific interventions within this level that we should discuss separately?" Level B, in particular, is a broad category. Understanding exactly which interventions are included and excluded at your specific Level B helps prevent misunderstandings.

• "If I'm transferred to another facility, does this form travel with me?" It should. Ask whether a physical copy accompanies the transfer, and whether the receiving facility's electronic system will have access.

For Paramedics and Emergency Situations

A niveaux de soins form placed prominently in the home — on the refrigerator, near the front door, or in a medical file that emergency medical services (EMS) know to look for — gives paramedics immediate guidance during a 911 response. Without it, paramedics default to full resuscitation.

If you or your family member lives at home and has a Level C or D care designation, keeping a signed copy visible is one of the simplest steps you can take to ensure emergency responders honour the established care preferences rather than initiating interventions that contradict them.

Getting Started

The DMA gives you a binding, pre-registered tool for the five treatments it covers — including CPR. The niveaux de soins conversation builds on that with a broader clinical framework that addresses everything else.

For worksheets to prepare for the goals-of-care conversation, plus the DMA treatment decision grid and emergency contact cards, the Quebec Advance Directive Kit includes the tools you need for both the advance planning phase and the clinical discussion phase.

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