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{{LSLAP Manual TOC|expanded = guardianship}}
An Advance Directive (AD) is a written document made by a capable adult that gives or refuses consent to health care, in the event that he or she becomes they become incapable of giving health care instructions. The legal provisions for AD’s are set out in Part 2. 1 of the HCCFA.
The health care provider is to make a reasonable effort in the circumstances to determine whether the adult has an AD, Representative representative or guardian. If the adult has both an RA and an AD, then the health care provider must seek consent from the Representativerepresentative. According to s 19. 3of the HCCFA, instructions in the AD will be treated as wishes expressed while capable, which are binding on a Representativerepresentative. However, the health care professional can act on the instructions in an AD without the consent of a Representative representative if the AD expressly states that: “a health care provider may act in accordance with the health care instructions set out in the advance directive without the consent of the adult’s Representativerepresentative. ”
The central purpose of an AD is to give or refuse consent to health care. If the adult has given consent in a valid AD, then the health care provider should provide that health care, and need not obtain the consent of a substitute decision-maker. Similarly, if the adult has refused consent in a valid AD, then the health care provider must not provide that health care, and need not obtain the consent of a substitute decision-maker.
If a health care provider is not aware that the adult has an AD that refuses consent to specific health care and provides that health care to the adult, but subsequently becomes aware of an AD in which the adult has refused consent, then the health care provider must withdraw the health care.
It is possible for an adult who does not complete an AD to still receive health care. Completion of an AD '''must not be mandatory''' prior to providing any good or service (i. e. health care). In other words, an adult has the right to not complete an AD. For example, where an adult is being admitted to a health care facility and instructed to “fill out these forms” prior to treatment, the adult does not have to fill out the AD. Adults are still eligible to receive health care treatment without completing an AD.
In the absence of an AD, if the adult has not appointed a Representativerepresentative, then the health care provider will seek consent from a Temporary Substitute Decision-Maker (TSDM), as set out in s 16 of the HCCFA.
== '''B. Note on Medical Assistance in Dying ''' ==
The Criminal Code of Canada was amended on June 17th, 2016, to permit the Medical Assistance in Dying (MAiD) under certain conditions. This means that a medical or nurse practitioner may, at the person’s request, administer a substance to cause their death, or prescribe a substance so that the person can self-administer a substance that causes their death.
Consent given through substitute decision makers, such as Representatives representatives under the RA ActRAA, and Advanced Directives are '''NOT''' sufficient for medical practitioners to provide MAiD. MAiD can only be provided to patients who are able to give consent as of July 15th, 2016.
This is because the College of Physicians and Surgeons of British Columbia’s “ProfessionalStandards and Guidelines” regarding MAiD clearly prohibit consent given through Ads ADs and RAs. The Professional Standards and Guidelines have weight in law pursuant to section s 5(2) of the Medical Practitioners Regulation under the Health Professions Act.
For more information on the Standards and Guidelines of the College of Physicians, please see their document on MAiD at: [https://www.cpsbc.ca/files/pdf/PSG-Medical-Assistance-in-Dying.pdfhttps://www.cpsbc.ca/files/pdf/PSG-Medical-Assistance-in-Dying.pdf].
== '''C. Making an Advance Directive ''' ==
An AD must include or address any prescribed matter and indicate that the adult knows the following:
*a A health care provider may not provide any health care for which the adult refuses consent in the AD; and*a A person may not be chosen to make decisions on behalf of the adult in respect of any health care for which the adult has given or refused consent.
For more information, refer to section '''[[Introduction to Adult Guardianship (15:III)#2. Health Care Consent | section III.B.2: Mental Capacity; – Health Care Consent]] ''' in this chapter.
For more information on preparing documents, consult the Appendix or organizations organisations such as Nidus Personal Planning Resource Centre and Registry. Contacting Contact information may be found in section '''[[Governing Legislation and Resources for Adult Guardianship (15:II)#C. Resource Organizations| section II.CD: Resource Organizations]] ''' of this chapter.
== '''D. Changing, Revoking or Ending an Advance Directive ''' ==
An adult with capacity is able to revoke or change an AD at any time. According to s 19. 6 of the HCCFA, an adult who has made an AD may change or revoke the AD as long as the adult is capable of understanding the nature and consequences of the change or revocation.
A change must be made in writing. The amended AD must also be signed and witnessed by two capable adults (unless one witness is a lawyer or notary).
A revocation may be made by expressing an intention to revoke an AD and then making another document, including a subsequent AD. Alternatively, an AD may be revoked by destroying the AD with the intention to revoke it.
== '''E. Examples of Advance Directive Provisions ''' ==
Examples of directives made in an AD might include consenting or refusing consent to the following: *CPR (if cardiac or respiratory arrest occurs); *artificial nutrition through intravenous or tube feedings; *prolonged maintenance on a respirator (if unable to breathe adequately alone); *blood cultures, spinal fluid evaluations, and other diagnostic tests; and/or *blood transfusions.
'''NOTE''': The adult should have their AD added to their doctor’s patient files, their hospital records, and any other relevant agencies. If the AD is revoked or altered, the adult should advise each of these agencies or provide them with the new or revised AD. === '''''1. Do Not Resuscitate Orders (“DNR Orders”) ''''' ===
Do Not Resuscitate Orders are a common form of AD which instruct medical professionals not to perform CPR. This means that doctors, nurses, emergency medical personnel, or other healthcare providers will not attempt emergency CPR if a person’s breathing or heartbeat stops. DNR orders Orders may appear in a patient’s advance directive document.
However, DNR orders can also be made in a hospital or personal care home, and noted on that person’s chart, or be made by persons at home. Hospital DNR Orders tell the medical staff not to revive the patient if cardiac arrest occurs. If a patient is in a personal care home or at home, a DNR Order tells the staff and/or medical emergency personnel not to perform emergency resuscitation and not to transfer the patient to a hospital for CPR.
Each hospital will have its own policies regarding the implementation of DNR Orders, but such policies are guided by the Joint Statement on Resuscitative Interventions (1995) which was approved by the Canadian Healthcare Association, the Canadian Medical Association, the Canadian Nurses Association and the Catholic Health Association of Canada and was developed in cooperation with the Canadian Bar Association. The Joint Statement can be located at httphttps://policybasewww.cmancbi.canlm.nih.gov/pmc/dbtw-wpdarticles/PolicyPDFPMC1488016/PD95-03.pdf.
Guiding Principles of the Joint Statement include: *A competent person has the right to refuse, or withdraw consent to, any clinically indicated treatment, including life-saving or life-sustaining treatment (Principle 3). In this situation, the healthcare professional will discuss with the patient whether the patient wishes to be resuscitated and a notation will be made on the person’s chart. *When a person is incompetent, treatment decisions must be based on his or her wishes, if these are known. The person's decision may be found in an advance directive or may have been communicated to the physician, other members of the health care team or other relevant people. In some jurisdictions, legislation specifically addresses the issue of decision-making concerning medical treatment for incompetent people; the legislative requirements should be followed (Principle 4).
== E'''F. A Practical Clinical Approach to an Advance Directive Note on ADs for LSLAP Students ''' ==
When a client approaches LSLAP for assistance with creating an AD, students should ask the following series of questions in order to ascertain whether LSLAP can assist them:
Students must also remember should refer to their legal responsibility to maintain professional conduct and client confidentiality. If abuse or neglect Supervising Lawyer if there is suspected, consult with any doubt that the Supervising Lawyer about how client understands and whether to make a report to appreciates the appropriate authorityAD. Refer Also note that an adult is not required to [[Adult Abuse and Neglect (15:VIII) | section VIII: Abuse and Neglect]]have an AD as a condition of receiving health care treatment.
If there are concerns that a person may be abused or neglected, or at risk of being abused or neglected, the student should discuss these concerns with the client and provide information and access to appropriate support services (e.g., Seniors Abuse & Information Line at 604-437-1940 or 1-866-437-1940).
Students must also remember their legal responsibility to maintain professional conduct and client confidentiality. If abuse or neglect is suspected, consult with the Supervising Lawyer about how and whether to make a report to the appropriate authority. Refer to section '''[[Adult Abuse and Neglect (15:VIII)|VIII: Adult Abuse and Neglect]]'''.
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