Green Sleeve Newfoundland: How the Clinical Program Connects Your Advance Directive to Emergency Care

The Problem the Green Sleeve Solves

You've signed your Advance Health Care Directive. Your Substitute Decision Maker has accepted the role in writing. Your two witnesses signed in your presence. Everything is legally valid under the Advance Health Care Directives Act, 1995.

Then you collapse at home. Paramedics arrive. They are legally mandated to perform full cardiopulmonary resuscitation — even if your directive says you don't want it — unless they can physically locate and verify a clinical order that says otherwise.

Your directive is in a filing cabinet upstairs. The paramedics don't know it exists. Full resuscitation begins.

This is the operational gap the Green Sleeve program was designed to close.

What the Green Sleeve Is

The Green Sleeve is a highly visible green plastic pocket designed to hang on your refrigerator door. It contains three documents:

1. Your active Goals of Care Designation (GCD) order — a medical order written by your physician or nurse practitioner that translates your values into one of three clinical designations: Resuscitation (R), Medical Care (M), or Comfort Care (C)
2. Your original Advance Health Care Directive (AHCD) — the legal document that records your treatment wishes and names your SDM
3. An emergency contact sheet — listing your SDM, family physician, and any other critical contacts

The refrigerator location is deliberate. Emergency responders in Newfoundland and Labrador are trained to check the fridge for the Green Sleeve. It's a standardized protocol — the clinical equivalent of looking for a fire extinguisher on the wall.

Why a Legal Directive Alone Isn't Enough

There's a structural disconnect between the legal system and the clinical system in NL that trips people up:

The legal layer is your AHCD — a document governed by the Advance Health Care Directives Act. It's what you write, sign, and have witnessed. It expresses your wishes.

The clinical layer is the Goals of Care Designation — a medical order that your physician writes based on your AHCD and a clinical conversation with you. This is what paramedics and hospital staff actually follow in real time.

A valid AHCD without a corresponding GCD order is like a building permit without a construction crew. The intent is documented but nothing is operationally in place. The Green Sleeve bridges these two layers by putting both documents in the same physical location where they can be retrieved in seconds.

How to Get a Green Sleeve

Ask NL Health Services, your family physician, nurse practitioner, or community health clinic how to obtain a Green Sleeve. If you are entering a personal care home or long-term care facility, ask its care coordinator about the local process. The clinical conversation with your physician to establish your Goals of Care Designation is separate from obtaining the physical sleeve.

Setting Up Your Green Sleeve

Step 1: Complete your AHCD

Your directive needs to be legally executed first — signed by you, witnessed by two qualifying people, and accepted in writing by your SDM.

Step 2: Book a Goals of Care conversation

Schedule a specific appointment with your family physician or nurse practitioner. This isn't a casual chat during a routine visit — you're asking your clinician to formally assess your healthcare values and issue a GCD medical order. Bring your completed AHCD to this appointment.

Step 3: Receive your GCD order

Your physician will discuss clinical scenarios with you (cardiac arrest, stroke, progressive organ failure) and translate your wishes into the appropriate designation:

• R (Resuscitation)
• M (Medical Care)
• C (Comfort Care)

Ask the physician to explain what interventions the selected designation covers in your situation.

The GCD order is a medical document that lives in your clinical chart and also goes into the Green Sleeve.

Step 4: Assemble the Green Sleeve

Place these three documents in the green pocket:

1. The signed GCD order
2. Your original AHCD (keep a clear copy in your physician's medical chart)
3. Your emergency contact sheet

Step 5: Post it on the refrigerator

Attach the Green Sleeve to the front of your fridge door using the magnetic strip or clip provided. This is the location paramedics are trained to check.

If You Live in a Personal Care Home or Long-Term Care Facility

For facility residents, submit the GCD order and AHCD copy for integration into the resident's clinical chart. Ask the facility's care coordinator where exactly these documents are stored and confirm they're accessible during shift changes and after hours.

Keeping It Current

Your GCD order should be reviewed and updated:

• At least annually during a routine appointment
• After any significant change in health — new diagnosis, hospitalization, change in functional status
• After any change to your AHCD — if you revoke, amend, or re-execute your directive, ask your physician to review and update the GCD to match
• If your SDM changes — the emergency contact sheet in the Green Sleeve needs to reflect the current person

An outdated GCD order in your Green Sleeve can be worse than no Green Sleeve at all, because clinicians may follow instructions that no longer match your wishes.

The Full Integration System

The Newfoundland and Labrador Advance Directive & Living Will Kit includes the complete Green Sleeve setup process — from the clinical conversation prompts for your GCD appointment to the distribution tracker that ensures every copy of your directive reaches the right hands. It's built around how NL's healthcare system actually operates, not how a generic template assumes it should.

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