Advance Care Planning

Advance Care Planning is about having a conversation with your family, friends and your health care provider, so they will know your health care wishes, if you become unable to communicate your own decisions.

What is Advance Care Planning?

Advance Care Planning (ACP) is about having conversations with your close family, friends and health care provider(s) so that they know the health care treatment you wish to have, or refuse, if you become incapable of expressing your own decisions.

What is an Advance Care Plan?

An Advance Care Plan is writing down your beliefs, values and wishes of your health and personal care preferences made while you are capable of providing consent to health care treatment or other care.

Why should I prepare an Advance Care Plan?

Preparing an Advance Care Plan is not only for seniors or people with terminal illness. At any age, a medical crisis could leave you too ill to make decisions about your health care. Everyone should prepare for end-of-life care because we can never know what the future may hold; accidents and terminal illnesses can, and do, occur suddenly. Writing down or recording your plan makes it easier for others to understand what’s important to you, and to make decisions for you if you couldn’t speak for yourself.

How do I make an Advance Care Plan?

You can write your Advance Care Plan by completing the Health Care Directive form [PDF | 185 KB] to set out your wishes or instructions respecting your health care and treatment in case a health care practitioner has determined that you are not capable to either make and/or communicate your own health care choices.  In your Health Care Directive, you can appoint a person or persons as your proxy(s), to make decisions for you when you are not capable to either make and/or communicate for yourself.

The Advance Care Planning on-line Interactive Workbook can help you through the advance care planning process and to write your Health Care Directive.  It includes:

  • Questions to help you think about the values and beliefs that influence your choice of health care options;
  • Definitions of medical terms you will need to know to make informed decisions about your health care options; and
  • Other information that may be useful in communicating with your health care team and family.

What else can I do?

Speak to your family, friends, health care providers and those who you would like to know about your plan. Give them a copy of your written plan if you would like. You can also complete an advance care planning Wallet Card [PDF | 836 KB] and carry it with you to let others know that you have a Health Care Directive and who can be contacted on your behalf in case of a medical emergency, if needed.

Can I change my Advance Care Plan later?

Yes. Your wishes for health care treatment may change over time or in response to your health condition. You can change your Advance Care Plan at any time. If you do update your plan, remember to advise your family, friends and health care providers so they know what your new goals of care are.

What are Goals of Care Designations?

Goals of Care Designations are instructions that guide your health care team about the general focus of your care and where you might want that care. After speaking with you and your substitute decision maker and/or proxy(s), your health care provider will write your Goals of Care Designation as a medical order on the Goals of Care form [PDF | 121 KB]. On the Goals of Care form three designation options exist:

  • R = Medical care and interventions, including Resuscitation – the focus is to extend or preserve life using any medical means including resuscitation
  • M = Medical care and interventions, excluding Resuscitation – medical tests and procedures are used to try to cure or manage an illness but no resuscitation or life support measures are used
  • C = care and interventions focused on comfort, excluding Resuscitation – the focus of care is to provide comfort to ease a person’s symptoms without trying to control or cure their illness.  No resuscitation is used.

Figuring out your Goals of Care is not just about finding out what your wishes are, but also about getting to know you better as a person. In a medical emergency, your Goals of Care Designation guides your health care team in providing timely care that best reflects your health condition, the treatments that will benefit you, and your own wishes and values.

Why are Goals of Care Designations important?

By knowing and following your Goals of Care Designation (R/M/C), health care providers care for you in a way that is timely, medically appropriate, and meets your values and wishes. It’s also an organized way for care teams to communicate about your care as you move between locations of care.

Goals of Care Designations are created just for you and your situation. They can change if your situation changes or if you want to change something you had previously decided.


Published date: 
August 12, 2020