Clinical Care Resources - Advance Care Plan

Advance Care Planning (ACP) is a process which gives someone the opportunity to consider and discuss with family, friends and health care team members their wishes and desires concerning future personal care options. This can be helpful in guiding their Substitute Decision Maker (SDM) if they ever become incapable of providing consent for health or personal care decisions. Some individuals may wish to write down preferences for care andtalk with health care providers or legal professionals.(1)

It is important for health care providers to understand the laws around capacity, consent and advance care planning for their province or territory. Health care providers should be comfortable providing information about the kind of care options that individuals may be offered in the future, educating individuals regarding the role and responsibilities of a Substitute Decision Maker (SDM) and supporting the individual to have conversations with their family and friends about their wishes.

Why is it important?

  • Health care decisions are becoming increasingly complex. Advances in medical technology mean that people with complex conditions are living longer; resulting in 70% of Canadians dying from a chronic disease.(2)
  • When surveyed, 6 out of 10 Canadians said that having end-of-life care discussions with at least one individual is extremely important. (3)
  • 52% of Canadians indicated that the advance care planning process should begin when a person is healthy, but only 13% had started the process. (3)
  • Individuals who have end-of-life conversations with their doctors/family members are much more likely to be satisfied with care received, require fewer aggressive interventions at end of life and are more likely to take advantage of hospice resources resulting in less strain on caregivers. (2)
  • End-of-life discussions and advance care planning can reduce moral distress for healthcare providers; affect outcomes such as completion of advance directives or powers of attorney for personal care; improve adherence to individual’s wishes. (2)

Key Considerations

  • Conversations should occur in a non-stressful environment and focus on individual’s principles, values and beliefs around end-of-life and what makes the individual’s life meaningful. Determine if the circumstances and burden of treatment outweigh the benefits of prolonged life; assess quality of life and discuss how the individual wants to live during the final stages (e.g. at home, pain-free). (2)
  • Focus on personal care: review possible treatments that may be considered for the individual’s condition, discuss implications of possible medical treatment (e.g. artificial ventilation, hydration, cardiopulmonary resuscitation), specify wishes with respect to organ donation or research participation, include their values, culture, faith and beliefs when discussing possible options.(2)
  • Health care providers should document discussions and decisions in the medical record and provide the individual with a copy; if they choose; it can be shared with family, loved ones, or substitute decision makers; periodically review and update the documents. (2)
  • It is important to ensure that the documentation is done in accordance with the provincial / territorial laws applicable.

Canadian Specific Resources:


  1. Canadian Hospice Palliative Care Association. (2012). Advance Care Planning in Canada: National Framework. Retrieved October 29, 2018 from
  2. Canadian Hospice Palliative Care Association. (2014). Fact Sheet: Hospice Palliative Care in Canada.Retrieved October 29, 2018 from
  3. Canadian Hospice Palliative Care Association. (2014). Fast Facts, Advance Care Planning In Canada. Retrieved October 29, 2018 from