First Nations Advance Care Planning and Palliative Care in Canada

Planning for Death in a Culture That Approaches It Differently

Western advance care planning focuses on legal documents — a signed directive, a named power of attorney, a do-not-resuscitate order filed with the hospital. First Nations advance care planning involves all of that, but it also means something deeper: communicating which ceremonies you want, who should tend the sacred fire, what medicines should be used, and where your body should rest.

Many First Nations families avoid talking about death until it arrives — a cultural tendency reinforced by generations of traumatic loss and a distrust of medical institutions rooted in residential schools and systemic racism. But the families who do plan ahead spare their loved ones from making agonizing guesses under extreme time pressure.

Culturally Safe Palliative Care

Palliative care in Canada is governed at the provincial level, and the quality of culturally safe care varies enormously by region. Some programs have made real progress in integrating Indigenous worldviews. Others still operate from a framework that treats traditional practices as quaint add-ons rather than central to the patient's care.

The First Nations Health Authority (FNHA) in British Columbia has been a leader in this space. Their "End of Life Journey" program provides resources for Indigenous patients and families navigating the health system. They also partner with Douglas College to train Indigenous End-of-Life Guides (IEOLGs) — community members nominated by Chiefs and health directors, trained in both Western palliative care and traditional worldviews. These guides act as supportive companions, not medical providers, helping families navigate the gap between hospital protocols and traditional expectations.

Indigenous Patient Navigators (IPNs) are available in many hospital systems across Canada, including Interior Health in BC, Muskoka Algonquin Healthcare in Ontario, and major urban hospitals in Winnipeg, Edmonton, and Saskatoon. When a First Nations patient enters palliative care, the IPN can:

• Coordinate access to traditional medicines and smudging within the hospital
• Arrange for Elders or Knowledge Keepers to visit the bedside
• Mediate between clinical staff and family members when cultural needs conflict with medical protocols
• Help with discharge planning when the family wants to bring their loved one home to the community for their final days

If you are navigating the hospital system with a family member in palliative care, ask for the IPN by name at admission or through the social work department. This is your entry point to culturally safe support within the institution.

Advance Care Planning for First Nations Patients

An advance care plan for a First Nations person should address both the medical and the cultural dimensions:

Medical decisions: Who has the legal authority to make health care decisions if the person cannot speak for themselves? In most provinces, this is done through a power of attorney for personal care or a representation agreement. The named decision-maker should understand the person's preferences about life support, resuscitation, organ donation, and the level of medical intervention they want.

Cultural and ceremonial preferences: These are rarely captured in a standard advance directive form, but they matter enormously:

• Should traditional medicines (sage, cedar, sweetgrass, tobacco) be used at the bedside?
• Should smudging be performed in the hospital room? (The Truth and Reconciliation Commission's Call to Action #22 calls on health-care systems to recognize and use Indigenous healing practices in collaboration with healers and Elders when requested. The family still needs to know how to request it under the hospital's policy.)
• Does the person want to die at home on the reserve rather than in a hospital?
• Who should be contacted to lead ceremonial preparations — which Elder, which Faith Keeper?
• Which funeral traditions should be followed? (This matters most in families where some members follow traditional practices and others follow Christian or secular approaches.)

Funeral and burial wishes: Where does the person want to be buried — on reserve, in an urban cemetery, or in a specific natural burial site? What kind of body preparation do they want? Do they want a four-day wake and sacred fire? Documenting these preferences in writing saves the family from having to guess during an already devastating time.

Hospital Smudging — How It Actually Works

A family can request smudging in a hospital, but the practical process involves coordination with hospital staff. A family member or the IPN contacts the charge nurse or spiritual care practitioner to initiate the request. Before the ceremony:

• Hospital security temporarily bypasses the local fire alarm zone
• The room must not have active oxygen therapy or be a positive pressure room
• A non-combustible container (abalone shell, stone bowl, or cast-iron pan) holds the smudge
• A wooden match is used, and a lidded non-flammable container is kept nearby for remaining ashes
• After the ceremony, security restores the alarm system

Knowing this process in advance — and knowing how to request it — removes a significant barrier for families who want traditional care at the bedside.

Bringing Someone Home

Many First Nations families want their loved one to spend their final days at home, in the community, rather than in an urban hospital. This requires coordination between the hospital palliative care team and community health services. The FNHA's End of Life Guide program can help facilitate this transition in BC. In other provinces, the hospital discharge planner and the community health nurse at the home reserve are the key contacts.

Planning for a home death also means ensuring the community is prepared: someone to build and tend the sacred fire, family members ready to begin the four-day wake, an Elder available to lead ceremony, and a funeral home or community helpers prepared for body preparation.

The First Nations Canadian Funeral Guide includes an advance care planning worksheet designed for First Nations families — covering both the legal documentation and the cultural and ceremonial preferences that standard forms leave out.