Advance Care Planning doesn’t have to be done all at once. This page outlines practical steps you can take to build your plan over time. You may find these steps don’t happen in a set order.
Need more background on this topic? Start by learning what Advance Care Planning involves.
1. Reflect on your values and beliefs
What matters most to you should guide your health decisions. Your views on medical interventions, independence, comfort, and quality of life are all relevant. You may explore these questions further using the Values Reflection Tool. You may also wish to reflect on cultural, spiritual, or family traditions.
2. Review your health status
Talking to your health care provider about your current health can help you think about your future care. Tools like the Clinical Frailty Scale can be used to assess how your health and independence may change over time. Frailty refers to a multi-dimensional decline in reserves – including energy, physical ability, cognition, and overall health – that can increase vulnerability to illness or stress.
3. Consider medical scenarios
Advance Care Plans often refer to hypothetical scenarios that outline how you would want care decisions made in certain health situations. These scenarios are not predictions, but prompts meant to help you reflect on what quality of life means to you and what kinds of medical treatment you would accept or decline in various situations. Find some example scenarios to consider.
4. Clarify your end-of-life preferences
Think about what would help you feel supported and comfortable. This may include accessibility needs, medical equipment, the level of support required at home or in a care setting, as well as emotional and personal considerations. Dying With Dignity Canada’s Advance Care Planning Kit helps you to think about and express these preferences.
5. Create your Advance Directive
An Advance Directive is a legal document that outlines your wishes for medical care if you become unable to communicate them yourself. For example, some people may want all available treatments if recovery is likely, but prefer comfort-focused care if treatment would only prolong life without awareness or independence.
The specific requirements for an Advance Directive vary by province and territory, but may include:
- your priorities for comfort, independence, and quality of life
- the types of medical treatments you would accept or decline
- specific instructions about end-of-life care
- the signatures of one or two witnesses
Download the right form for your province or territory from the Dying With Dignity website.
6. Appoint your Substitute Decision-Maker
A Substitute Decision-Maker will make medical decisions on your behalf if you become unable to make them yourself.
Consider someone who:
- meets the minimum age requirement in your province or territory
- understands your values and wishes
- is comfortable speaking with health care providers
- can make decisions during difficult situations
Before naming someone, make sure they’re willing to take on the role. Some people choose the same person for multiple roles, such as their Substitute Decision-Maker, executor, or Power of Attorney. Others choose different people.
8. Revisit your plan
Your Advance Care Plans can change as your health and priorities evolve. Review your plan regularly with supporters and health care providers, especially as your medical condition changes. If you reconsider some of your decisions, be sure to document those changes and inform your Substitute Decision-Maker.
Start where you are
End-of-life planning isn’t something you need to figure out all at once. You can return to these questions over time, and your answers may change. What matters is making your wishes known to the people who support you. Learn how to start conversations about end-of-life.