Individuals in any role should ensure that they have current accurate Ontario legislation information where applicable and has appropriate skills for the conversation/assessment.

NSM Hospice Palliative Care Nurse Consultants (HPCNC):

  • Provide education regarding/supporting Advanced Care Planning and Goals of Care Conversations. Click ‘Education’ button below to request education session.
  • Provide additional support to patient/family. Click on ‘Referral’ button below to submit referrals to HPCNC/social worker.

Education              Referral

Advanced Care Planning

Is a guided conversation, confirming with the person in front of you:

  • Do they know what a substitute decision maker (SDM) is?
  • Do they understand who their automatic SDM would be?
  • Is this the person they want making their health care decisions?
  • Are they aware of the need for Power of Attorney for personal care?
  • Do they understand what the role of the SDM may be in the future?
  • Do they understand Advanced Care Planning conversation as an ongoing conversation to have with their SDM, to keep them up to date as life changes happen?

Advanced Care Planning:

  • is NOT consent for care
  • is NOT about code status, i.e. filling out D.N.R. forms.
  • Does funnel down to a final decision about consent.
  • Advanced care planning itself is NOT consent.

Goals of Care

Goals of Care conversations is the second step in a 3-step process of eventually gaining consent to treatment.  The GOC focus on understanding the nature of the illness, and helping healthcare providers (e.g., nurse, doctor, or social worker) secure the goals of the patient by understanding what the patient desires as an outcome.  Accurate Goals of Care help in treatment decisions, and, ultimately, help provide informed consent.

Starting a conversation with your patients about their beliefs, wishes and goals of care may not be easy, but it is an important process. By asking why they have made some decisions like, “No heroic measures”, will start them thinking about their values and wishes. Most people value the potential outcome of a treatment and not the treatment itself.  You may learn they value being able to meaningfully interact with those around them, value being able to independently think and make decisions, or being able to communicate their needs.  Having values communicated and in place will greatly contribute to quality of life and of themselves and their loved ones if they were mentally incapable of making decisions. It is important that they participate in this conversation and share their wishes now, while they are able to do so.

As a health care provider, having answers to critical questions, such as:

  • If something happened to your health and you became unable to speak, who would make decisions on your behalf? (Substitute Decision-Maker)
  • If time were limited, what would be most important for you?
  • Where would you prefer to spend your last days? At home, in a long-term care facility, hospital or hospice.

Consent for Treatment of Care

  • Is a conversation a healthcare provider must have with a person or their SDM, prior to the initiation of any treatment or personal care?
  • SDM only acts when the person lacks capacity – ability to understand the information & appreciate how the outcome or result will affect their life.