How to Ensure Paramedics Follow Your End-of-Life Wishes in Nova Scotia

If your plan is to write a Personal Directive, put it in a drawer, and assume that's enough — it won't work. Nova Scotia EHS paramedics cannot use a Personal Directive alone as the emergency medical order. The current Goals of Care and Levels of Intervention (GOC) form (CL-AS-005), completed by the Most Responsible Health Care Provider or an Authorized Prescriber, records the active clinical instructions; the older Do Not Resuscitate and Allow Natural Death forms were retired from the Nova Scotia Health system on July 23, 2024. Your Personal Directive, no matter how carefully written, is a legal document — not a medical order. Paramedics need specific clinical instructions, displayed in a specific place, completed by the responsible clinician.

The system that makes this work in Nova Scotia has three layers: the Personal Directive (legal authority), the current Goals of Care and Levels of Intervention form (clinical authority), and the Green Sleeve (physical access). If any one of these layers is missing, your end-of-life wishes may not be followed when it matters most. Here's how to connect all three.

The Gap Between Legal and Clinical

Most Nova Scotians complete one layer and assume they're done. They write a Personal Directive and file it. Or they have a conversation with their doctor but don't formalize it. Or they've heard of the Green Sleeve but don't know what's supposed to go inside it.

The reality is that these three systems were designed by different parts of the healthcare system — the Department of Justice (legal), Nova Scotia Health (clinical), and EHS (emergency) — and nobody built the bridge between them. Families are left to figure out the connections on their own.

Here's what each layer does and why you need all of them:

Layer 1: Personal Directive (Legal Authority)

Your Personal Directive, created under the Personal Directives Act (2010), does two things: it appoints a delegate to make healthcare decisions on your behalf if you lose capacity, and it records your treatment instructions. This is the legal foundation. Without it, healthcare providers must use the statutory hierarchy to identify a substitute decision-maker — which may not be the person you'd choose.

What it doesn't do: it doesn't give paramedics or emergency physicians a medical order they can act on in real time. EHS paramedics arriving at your home at 2 AM are trained to provide life-saving treatment. They're not trained to interpret legal documents.

Layer 2: Goals of Care and Levels of Intervention Form (Clinical Authority)

The Nova Scotia Health Goals of Care and Levels of Intervention form (form CL-AS-005) is a clinical document completed by the Most Responsible Health Care Provider or an Authorized Prescriber. It translates your values and treatment preferences into medical language that clinical staff can follow. It records your goals of care designation — ranging from full active treatment to comfort-focused care only.

The older Do Not Resuscitate (DNR) and Allow Natural Death (AND) forms were retired from the Nova Scotia Health system on July 23, 2024. The current GOC form carries clinical authority as the active order completed by the responsible clinician. Your Personal Directive informs the conversation, but the clinician's completed GOC form gives paramedics and hospital staff their current instructions.

Layer 3: The Green Sleeve (Physical Access)

The Green Sleeve is a green plastic folder distributed by Nova Scotia Health. You keep it on your refrigerator — on the outside, visible, with a sticker that says "In Case of Emergency." EHS paramedics throughout the province are trained to check the fridge for this folder when they respond to a call at a home.

Inside the Green Sleeve, you should have:

• Your Personal Directive (or a copy)
• The completed Goals of Care and Levels of Intervention (GOC) form (CL-AS-005)
• An EHS Special Patient Program care plan, if enrolled
• An Expected Death at Home form, if you're under palliative care and planning to die at home

The Green Sleeve is the physical mechanism that puts everything in the right hands at the right time. Without it, paramedics may never see your documents.

The Step-by-Step Process

Step 1: Complete Your Personal Directive

Write a Personal Directive that includes specific, scenario-based treatment instructions — not vague statements like "no extraordinary measures." Appoint a delegate who understands your wishes and can advocate for you. Have the document witnessed according to the Act's requirements (one witness who is not your delegate or their spouse). Store the original safely and make copies for your delegate, your doctor, and your Green Sleeve.

Step 2: Book a Goals of Care Conversation

Call your family doctor's office and request an appointment specifically for advance care planning. Bring your Personal Directive. During the appointment, your Most Responsible Health Care Provider or Authorized Prescriber will discuss your treatment preferences across different scenarios — sudden cardiac arrest, progressive organ failure, severe stroke — and complete the Goals of Care form based on your conversation.

If your goals of care include not wanting CPR, the responsible clinician records the applicable instruction on the current Goals of Care and Levels of Intervention form. This is the current clinical order available to EHS paramedics.

Step 3: Get and Stage Your Green Sleeve

Request a Green Sleeve from your family doctor, local health centre, or palliative care team. Place your Personal Directive and current Goals of Care form inside it, along with an EHS Special Patient Program care plan or Expected Death at Home form if applicable. Attach it to the outside of your refrigerator where it's clearly visible.

Carry a wallet card or phone note that says you have a Green Sleeve at home with your advance care documents. If you're admitted to the hospital, make sure the admitting team knows about your documents and gets copies.

Step 4: Enrol in the EHS Special Patient Program (If Applicable)

If you have a chronic or terminal condition that may result in frequent ambulance calls, ask your doctor about the EHS Special Patient Program. This creates a care plan on file with Emergency Health Services so that dispatchers and paramedics know about your medical history and treatment preferences before they arrive.

Step 5: Tell Your Delegate and Family

Your delegate needs to know where the Green Sleeve is, who your doctor is, and what the Goals of Care form says. If your delegate lives out of province or is unavailable during an emergency, have a backup plan — an alternate delegate or a family member who knows where to find everything.

The Comparison Table

Who This Is For

• Anyone in Nova Scotia who has completed a Personal Directive but hasn't connected it to the clinical system
• Families with an aging parent who is approaching palliative care or has a terminal diagnosis
• People who want to die at home and need EHS to respect that choice when 911 is inevitably called
• Caregivers managing a parent's end-of-life planning from a distance and need to ensure the right documents are physically accessible

Who This Is NOT For

• People who want full active treatment in all circumstances — you likely don't need a non-resuscitation instruction, though a Personal Directive appointing a delegate is still valuable
• Someone who already has a Green Sleeve staged with current Goals of Care documents
• Situations requiring hospital-based advance care planning (e.g., ICU admission with imminent decisions) — these follow a different clinical pathway led by the hospital team

How a Dedicated Kit Helps

The Nova Scotia Advance Directive & Living Will Kit is built around this exact three-layer connection. It includes a Goals of Care Appointment Card with the questions to bring to your physician, a Green Sleeve Staging Worksheet that walks you through requesting the folder and filling it, and a Document Storage & Access Log to track who has copies of what. The kit is designed to bridge the gap that the government forms leave open — the operational steps between signing a legal document and having it work in a medical emergency.

Frequently Asked Questions

Can paramedics legally ignore my Personal Directive in Nova Scotia?

They don't ignore it — they can't use it as the emergency medical order by itself. A Personal Directive is a legal document that appoints a delegate and records your wishes. Paramedics are trained to follow medical orders, not legal documents. The current Goals of Care and Levels of Intervention form records CPR and other treatment instructions. An EHS Special Patient Program care plan may also provide relevant information if you are enrolled.

What if I have a current Goals of Care form but no Green Sleeve?

If paramedics can't find your current Goals of Care form when they arrive, they may not have access to the clinical instructions at the scene. The Green Sleeve is the retrieval mechanism — it tells paramedics where to look. Some people carry a wallet card, but at home, the fridge-mounted Green Sleeve is the standard that EHS is trained to check.

What if my clinician won't complete a Goals of Care form?

The responsible clinician completes a Goals of Care form after a clinical conversation about your condition, prognosis, and preferences. If your clinician is uncomfortable with the discussion, ask for a referral to a palliative care physician or request a Goals of Care conversation through your local health authority. You have the right to refuse treatment, and a properly completed Goals of Care form records that refusal in language the clinical system recognizes.

Does the Green Sleeve work if I'm in a care home, not at home?

Care homes have their own systems for storing advance care documents. When you're admitted to a long-term care facility, your Personal Directive and Goals of Care form should be placed on your medical chart. The Green Sleeve is primarily for home-based care, but the documents inside it are the same ones the facility needs.

Can my family override my Green Sleeve documents?

Not if you have a valid Personal Directive. Your delegate is legally bound to follow your written instructions, and healthcare providers must follow the current clinical orders recorded on the Goals of Care form. Family members who disagree with your wishes cannot override a valid Personal Directive or those current clinical orders. This is one reason why explicit, specific treatment instructions matter — vague language gives more room for dispute.

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