Unplanned hospitalizations – and coronavirus – must trigger advanced care planning discussions

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  • Judith Wahl says:

    What is missing in this article and in most articles I see about advance care planning is a discussion of and understanding of the the duty of health practitioners to get an informed consent before treatment and the rights of patients to not be bound by wishes about future care that too often are expressed before they have a informed understanding of their state of health and what they could expect or possibly anticipate could happen to them.

    I have seem many documents recently circulated by the LTC Clinicians Association, by individual health practitioners, even by the Ministry of Health in response to Covid that illustrate the deep rooted misunderstandings about advance care planning and the duties of health practitioners to have discussion in real time with patients or their SDMs if the patient is incapable about the patients real state of health and the possible options,.both those recommended by the health practitioner as well as those treatments that are not being offered because the patient would not benefit from that treatment. these discussions to get decisions must take place even if the patient previously engaged in ACP and expressed wishes about future care. Those acp wishes should not be used to limit discussions or to offer possible treatments even if the patient had express a wish not to have certain treatments before getting full information on their health condition and Actual not speculative treatment options.

    Too many practitioners think ACP helps a patient make a decision about future treatment in advance when in fact that is far from the truth or the law or the ethics. Any ACp wishes are not consents or refusals of consent to future treatments. Acp wishes cannot be used directly by clinicians to direct care in real time. Yes the advance discussions discussions are important and need to be done BUT these are not more important than ensuring that a discussion takes place with patients or SDMs in real time when actual decisions need to be made by them with knowledge of the impact of the health problem, and the possible options for treatment with info on the risks, benefits, alternatives to these options and what would likely happen if the patient or SDM refused the treatments offered.

    I have reviewed numerous research studies done on advance care planning and sadly most of the studies have ignored what the law on informed consent and health decision making is in the jurisdiction in which the research was done. So the results are skewed because the legal framework was not considered before the research was done.

    Numerous health facilities and services of all types use forms .. be it electronic forms or paper – related to ACP and Consent that do not reflect or respect the law on health decision making that has been in Effect in Ontario since 1995. A study I coauthored with two others found that a review of such forms and policies used in 100 health facilities like Ltc homes and hospitals and health services like family practice units contained significant misinformation on health decision making. Not one set of the 100 reviewed were completely legally correct. Common errors related to who was a patients SDM if the patient lacked capacity to make health decisions, how ACP wishes should be treated when actual decisions about treatment needed to be made, how forms like “written advance directives” or “ levels of care” should be used to determine what treatments should be offered ( by the way they should NOT influence what care to offer) , what is the difference between goals of care and informed consent, and so on.

    I am now working on commentaries on all the documents I have found as posted by physicians, various health practitioners groups, by the MOHTC on acp and treatments to be offered or not in light of COVID to identify the legal flaws in an effort to try to turn the boat… this major huge ocean liner of misunderstandings about ACP and health decision making to help refocus attention on what is actually required to be done to support both appropriate ACP AND health care decision making that must be done in real time when decisions must be made.

    Failure to respect the law on health decision making takes away the rights of patients and their SDMs in health decision making, is the direct opposite of patient focused care, and exposes health practitioners to possible claims of medical malpractice and professional misconduct so it’s not good for any of the players in this process.

    In the end all this research and work done on AcP and health decision making has the good intent of ensuring care is patient focused. It has the intent to support patients, SDMs and the health practitioners particularly when difficult discussions and decisions need to be made. But these goals and good intents will not be realized if the basic legal framework on health decision making , much of which has been the law across Canada since the early 1970s and then codified in statutes such as the Health Care Consent Act passed in Ontario in 1996 , continues to be ignored.

  • Susan Greenfield says:

    This is a terrific article and written with such candid simplicity. It’s a discussion I’ve had a lot over the last years with my family and friends and I finally decided to go ahead this hear and get it all down on paper and talk to the people that need to know my wishes. Oddly, instead of being macabre, it feels kind of peaceful to feel that my wishes are known and that I am sparing people who love me the pain of having to make decisions at a time when they are grieving or scared. I feel it is a very loving thing to do for others and yourself. Thanks so much for writing this article
    Susan Greenfield

  • Jane Meadus says:

    The writer indicates that Advance Care Planning is NOT the same as a living will. True, since in Ontario, and I believe in the rest of Canada, “living wills” are not legal documents. People should be looking to their provincial legislation to determine what the requirements are for appointing decision makers (in Ontario a power of attorney for personal care) and how to make wishes known (in Ontario there is no format required, most recent wishes over older, only used if person incapable, substitute decision maker to comply with wishes).

  • Cherie Curry says:

    Thank you for tackling this subject. I look forward to hearing about more of these conversations and more education for the general public. I would also like to hear about options for completing MOST and DNR forms if clients are not attached with primary care providers. How can these people be supported in these important conversations more fulsomely?

    • Kieran Quinn says:

      Hi Cherie,

      I think there is a great opportunity to utilize our Telehealth services (OTN in Ontario) to engage in these discussions with primary care physicians. The Ontario Government just approved new fee codes to incentivize this practice. Please contact your primary care provider to setup an OTN call ASAP!


Kieran Quinn


Kieran Quinn is a general internist and palliative care physician at Sinai Health System and an early career health services researcher affiliated with the University of Toronto and the Institute for Clinical Evaluative Sciences (ICES).

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