Today is National Advance Planning Day in Canada. This day is intended to prompt the difficult conversation that most people tend to avoid for the other 364 days a year. There is a lot of confusing language out there regarding advance planning. This article seeks to clarify the terminology and provide some practical considerations.
Personal Directives
Personal Directives are sometimes referred to as “living wills”, “advance directives”, or “directives to physicians”. In Alberta, the official term is “Personal Directive”. It is a document that allows a person to designate an alternate decision-maker (called “Agent”) in relation to personal and health decisions. It may also set out specific wishes and guidelines that the person would like their Agent to follow when making decisions for him or her. For a detailed summary of Personal Directives, see here.
Goals of Care Designation
“Goals of Care Designation” is a medical designation/order made by a physician in regards to a patient. The Goals of Care will indicate the patient’s specific and general medical care intentions, preferred locations of care, and gives transfer opportunities for current and future care of a patient being treated in Alberta. It is a piece of short-hand communication to all members of a patient’s health care team about the patient’s intentions and wishes.
Goals of Care are discussed and created during the course of care and treatment, ideally the earlier the better. The Goals of Care will communicate to the health care team of the intended care level is for the patient. In determining this, the health care team consults with the patient, if he or she has capacity. If he or she do not have capacity, this is when the Personal Directive becomes important. The Agent designated in the Personal Directive will then consult with the physician regarding the intended care level. In those consultations and any decisions made accordingly, the Agent will be bound by what is set out in the Personal Directive.
There are three main categories in a Goals of Care (with subcategories in each)[1]:
- Resuscitative (R): The focus is to extend or preserve life using any medical or surgical means. This includes, if needed, resuscitation and admission to the intensive care unit.
- Medical Care (M) – Medical tests and interventions are used to cure or manage an illness as well as possible but don’t use resuscitative or life support measures.
- Comfort Care (C) – The focus of care is to provide comfort to ease a person’s symptoms without trying to control the underlying illness.
A “Green Sleeve” is a plastic pocket belonging to a patient that contains:
- Goals of Care Designation order, when one exists;
- Advance Care Planning Goals of Care Tracking Record;
- Personal Directive copies, if they exist;
- Guardianship Order, if one exists; and
- “Expected death in the home”, if one exists.
Practical Considerations
These are difficult, but important, topics to discuss with family members. Often people say that their family knows what they would want and forego a detailed conversation about illness and incapacity. However, when these circumstances do arise, family members are often stricken with grief and stress. Careful and considered decisions rarely come out of that kind of emotional state. That is why is best to set out what your intentions and wishes are in the Personal Directive. It alleviates the pressure for your family to “make the right decision” and ensures that your wishes are met, when possible.
In addition to the specific medical considerations you may want, you should also consider these practical matters:
- Whoever you name as your Agent may need to make decisions suddenly and urgently. It should be someone you trust but also should be someone accessible. Can they be reached in the middle of the night or mid-work day? Will they be available in Alberta to consult with your health care team?
- Consider the dynamics between your Agents (if multiple) or your Agent with other family members. Will the designation create additional stress? Will there be conflict over the decision-making?
- Remember that if you are naming your children to be your Agents that they are used to having you be their caretaker, meaning that they probably turn to you for the answers to questions they cannot figure out. It is very important to set out your specific wishes and intentions in your Personal Directive because children will feel the pressure of “making the right decision” more than most.
- Keep your Personal Directive somewhere that is accessible to your Agent (or give them signed Personal Directive). For example, if you are sent to the hospital in the middle of the night, your Agent will not be able to grab the Personal Directive if it is locked somewhere in your house or in a safety deposit box.
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