What is an Advance Directive?

As part of your Advanced Care Planning you may decide to put in place an Advance Direction. An Advance Directive is a written instructions made by a capable adult directly to the adult’s health care provider to give or refuse consent for health care:

• It is a legal document dated, signed and witnessed.
• It is used when the adult is not capable of giving instructions at the time the health care is required.

This distinction between a Representation Agreement , a Power of Attorney, an Advance Care Plan, and an Advance Directive is absolutely essential information.  For more information about these documents, check with your legal team to find out the laws about each in your area. Briefly, the distinction is as follows:

• Representation Agreement is a legal document that names the person or persons who will speak for you if you are incapable of speaking for yourself.
• Advance Care Plan (May be oral or written (preferable). It is not a legal document in my Province (it may be legal in yours--check with your legal team).  It sets out the wishes of an individual with regard to the kind of care and treatments he or she wants to have.  It can include end-of-life care.
• Advance Directive (AD) is a written legal document that is to be given to health care providers to guide them in providing care when the patient is unable to speak for him or herself.  
• Power of Attorney – This document does not deal with health care.  It deals with financial and legal matters.

When AD May Not be Followed 

• When a Personal Guardian (Committee of the Person) appointed by the Supreme Court disagrees.
• When the AD does not deal with the health care decision at issue.
• When it is unclear what the adult wanted.
• When it is in conflict with the patient`s known wishes, values or beliefs.
• When changes in medical knowledge, practice or technology might substantially benefit the patient, unless it states that it applies regardless

Remember that only when the patient cannot speak for him or herself will the Advance Directive be used. As a result, the document must be very carefully worded. 

Example:  The Advance Directive (AD) states that the patient does not want to be attached to machines. What exactly does that mean?  Some ‘machines’ such as an IV drip are quite routine and others are very sophisticated.

The medical team will do their best to follow your AD, however they can only follow it if it is clearly written.  That is why specific language must be very carefully considered. For example saying “I do not want to be resuscitated if my representative is satisfied that my illness is terminal and I am expected to die within the next six months.” is not a directive. It is a statement that expresses a preference but not a specific instruction.  It would require interpretation and judgement and cannot stand alone.

However, putting the following in writing: “I refuse consent for blood transfusions in any and all circumstances.“ would be considered a directive because this statement expresses clearly what treatment is involved and describes the specific circumstances when it applies.

Consent is required for all types of health care with two exceptions:

• Preliminary examination, treatment or diagnosis if the patient has indicated that he or she wants the health care; and
• Urgent or emergency health care that is necessary to preserve life, prevent serious physical or mental harm or to alleviate severe pain.
• When the patient is stabilized then the rules of consent apply.

The above is very important because it clearly lays out that treatment will be given should the patient enter a health care facility.  Just by going to the emergency department shows that a patient wants health care.  Note that the rules of consent (the AD document) will apply AFTER the patient is stabilized.

Remember:  Decisions are going to be made by somebody. This is why a Representation Agreement is strongly advised. Perhaps the patient does not want his or her spouse to be put in the position of making life or death decisions, or the patient has several children and has definite ideas about who should represent him or her.  Without a Representation Agreement, the medical personnel will use whichever child they can reach first.

Source: The information from the last two posts on Advanced Care Planning and Advance Directives come from various sources including MyVoice Booklet and COSCO Health and Wellness Workshop on Advanced Care Planning