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On this page
Summary of Advance Care Planning for Final Affairs
Detailed Menu for This Page
Short List of Legal and Medical Final Affairs Documents
Why are Advance Directives and Representation/Health Proxy Agreements important?
Questions and Answers about Advance Directives
Questions and Answers about Representation/Health Proxy Agreements
Dementia and Advance Planning
Advance Planning for the Pan-Death Process
 

Advance Care Planning

Advance care planning (ACP) is a key factor in ensuring that your wishes and directives are fulfilled, in terms of medical and personal end-of-life care, as well as death arrangements.   As the options available become more complex in our modern-day world, it is important to have your directives written down — with copies given to all who would be involved in your medical treatment and final affairs.   This can be overwhelming, so we encourage you to find someone to guide you through the complexities.


Summary of Advance Care Planning for Final Affairs

On this webpage, CINDEA provides a description of the documents that may be required to plan your end-of-life affairs.We have attempted to answer some of the questions you may have about Advance Directives and Representation/Proxy Agreements, in particular, which are perhaps the most important of these documents as far as medical matters go.   In addition, we have provided a brief checklist (at the end of this page) of some of the matters you may wish to consider as part of your own advance-care planning.

This page also includes a short overview of dementia and how it is connected to advance planning.   Dying with dementia is becoming increasingly common as people live longer, since medical treatments have been found for many other illnesses.   The modern-day phenomenon of dementia has many issues associated with it that our culture and our medical system have not yet resolved.   Nonetheless, dementia is a factor that needs to be seriously considered during the advance-planning process, as you may not be able to make the necessary decisions if you are affected by this condition in the future later in life.


Detailed Menu for This Page
Summary of Advance Care Planning for Final Affairs
Short List of Legal and Medical Final Affairs Documents
 
  Will
  Power of Attorney
  Expressed Wishes/Personal-Care Wishes
  Advance Directive/Health Care Directive/Personal Directive
  Representation/Health Proxy Agreement
Why are Advance Directives and Representation/Health Proxy Agreements important?
Questions and Answers about Advance Directives
 
  What is an Advance Directive?
    Condensed Advance-Directive Template
  What is the value of having an Advance Directive?
  Is having an Advance Directive absolute assurance that your wishes/choices will be followed?
  Is an Advance Directive a legal document?
  What is the difference between an Advance Directive and Expressed/Personal-Care Wishes?
Questions and Answers about Representation/Health Proxy Agreements
 
  Who makes medical decisions for you if you can't?
  What is a Representation Agreement?
  What is a Representative?
  Does a Representation/Proxy Agreement need to be signed by a lawyer?
  Which has more power — an Advance Directive or a Representation/Proxy Agreement?
Dementia and Advance Planning
Advance Planning for the Pan-Death Process
 
  Matters to consider in advance-care planning

 


Advance Planning of Legal and Medical End-of-Life Affairs
Short List of Final Affairs Documents

Please note: Some of these documents have different names, depending on what province or territory you live in.   The particulars may also be somewhat different, so please check on the specifics for your area.   The term 'Advance Directive' will be used for all references to advance health-care choices.   The term 'Representation Agreement' will be used for the document that specifically designates the person you have chosen to fulfill the Advance Directive, or who will make medical decisions that it does not cover.   A Substitute Decision-Maker may also be referred to as a (default) Proxy.


Will:
Contains legal instructions on how to distribute the assets in the estate after death; if there is no will, the law determines distribution.   Legal will kits are available through various organizations listed on our Resources in Canada — Pre-Death page.   If you have multiple assets, or your desires for their distribution are complex (multiple recipients, trusts, etc.), we advise that you consult a lawyer who specializes in estate law.

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Power of Attorney: A power of attorney (PoA) is used to delegate financial and most legal decisions — but generally not healthcare decisions — to a person of your choice (usually a friend or family member) while you are alive.   If you don't have a relative or friends who can serve as power of attorney, you can designate a respected professional such as your lawyer, accountant or trust company — but be aware that their services may be quite expensive.   After you die, all financial and legal decisions are made by your executor, not by the person who has your power of attorney (unless they are the same person).

There are generally 4 kinds of PoA documents:
    general or regular (not commonly in use any more)
limited (only a stop-gap measure when travelling/etc.)
enduring/continuing (in effect as soon as signed, and continuing until it is revoked, or until death) the most common form
springing (so called because it springs into effect in specific named circumstances — usually when the person is no longer fully capable of making their own decisions)

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Expressed Wishes/Personal-Care Wishes: "Expressed wishes" is a term that refers to choices — particularly for end-of-life care — that are not specifically medical, but address personalized 'quality of life' (frequently referred to as "personal care").

Expressed wishes may include
    alternative therapies
  nutrition and hydration needs and preferences
  safety issues
  residence and clothing preferences (where possible)
  special hygiene needs
  preferences for recreation and social activities (where possible)
  things to do or not do to avoid discomfort or annoyance
  personal issues and anything of specific concern to the person
spiritual-care issues
— as well as choices throughout the pan-death process (pre-death care, active dying stage, post-death care, funeral/memorial, etc.   See CINDEA's Post-Death Care page).

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Advance Directive/Health Care Directive/Personal Directive/Power of Attorney for Personal Care (or Health Care) — sometimes called a Living Will: Details your wishes for medical treatment/care if you are no longer able to make your own decisions or communicate them (see below for detailed description of Advance Directives).    

  If no Advance Directive exists, decisions on treatment/care will be made by your Representative or substitute decision maker.
  The default designation of who would be your substitute decision maker is determined by a list, with a specific ordering of blood/marriage family members — and in some provinces/territories, other people, such as closest friends.
  If no Representative or substitute decision maker is available, decisions will be made by the medical staff, based on normal practice (and most often directed towards continuing life -— the medical default position).

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Representation Agreement (RA)/Health Proxy (or Agent) Agreement: If no RA exists, and there is no appropriate substitute decision maker, the courts will appoint a legal guardian.   Be aware that whether either form of RA (below) requires a lawyer may vary from one province/territory to another.   The table below is drawn from the requirements in B.C. as of the date this is written (October 2011). [Note: If you are unclear about your needs, we advise that you talk to a lawyer who specializes in Elder Law.]
 
    Standard Agreement: designates person(s) who will be your Representative/Health Proxy and make decisions for non-life-threatening medical conditions/circumstances, and possibly deal with routine finances and personal care.   May not require a lawyer's signature. [Note: in some provinces/territories such as in B.C. it may be possible for an adult to sign a standard agreement after they are 'deemed incapable': the focus is on 'degree of capability', rather than a simple 'is or is not capable'.]
Enhanced Agreement: designates person(s) to be your Representative/Proxy for all medical decisions, including those which are life-threatening.   If there is no such agreement, and no substitute decision maker is available, life may be extended beyond — and by means against — the wishes of the patient [Note: a Standard RA does not automatically extend to become an Enhanced one, if one's medical situation becomes life-threatening.]   May require a lawyer's signature (as of September 2011, this is no longer required in B.C.).

Please note: much of the information on pre-planning confuses the two issues of (a) what choices are to be made, and (b) who will fulfill (or make) them.   For example, a Personal Directive is commonly considered to be the same as the older term for an Advance Directive — 'living will' — but a Personal Directive (such as the one in Nova Scotia) includes a designation as to who will make decisions for you when you no longer can (similar to a Representation/Health Proxy/Power of Attorney for Health Care Agreement).   We advise that you make a clear distinction between (a) your written instructions/choices on health care (the Advance Directive), and (b) the written agreement as to who will fulfill your Advance Directive choices and make all unforeseen decisions (generally called the Representative or Health Power of Attorney).   Part of the problem here is that there is — as yet, but this seems to be changing — no standardization of terms or legislation in Canada.

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Why are Advance Directives and Representation/Health Proxy Agreements Important?

In earlier generations, families tended to live close by and to share traditions, values, religion, and lifestyle choices.   The medical options were limited — especially for terminal illness and 'extreme measures' treatments (which has primarily developed since the 1970s).   People usually died before they reached a prolonged state of severe dementia, coma, or critical chronic illness.   

As a result, family members usually knew what each other's end-of-life wishes were, and were available to fulfill them.

 

Fire
— remembrance flower mandala by Elli Boray

With the medical and cultural changes of the 20th century, end-of-life choices are no longer so straightforward.   Family members often live great distances from one another, and may not be available when decisions need to be made.   Given divorce, re-marriage, and/or common-law situations, there may be serious questions as to who would be recognized as legitimate/legal family (re the substitute decision maker list).   Because of medical advances (especially with chronic illnesses) and increased longevity, close family members (such as spouse or siblings) — who would normally make end-of-life decisions for each other — may not be fully mentally or physically capable of doing so.   In our present global/multi-cultural world, traditions have greatly diversified within families, and the traditions themselves are changing exponentially (as are the reasons — such as ecological awareness — for them doing so): as a result, family members may hold very different values, or have very different ways of expressing them.   Some families still are physically close and share traditions, values, and lifestyle choices: however, in many cases, it may be close friends — or members of an intentional community one belongs to (faith, etc.) — who are both willing, and able, to fulfill one's end-of-life choices.

This modern situation also means that it is more possible, and advantageous, to specifically personalize our end-of-life choices — both medically and otherwise (personal care, post-death care and arrangements, etc.).   As cultural traditions change, there is both a need to clarify our personal choices, and the opportunity to do so, according to our own values.   As such, it is necessary for all of us to discuss these matters with our families, friends, and communities; be very clear about what we want; and ensure that reasonable arrangements are made to fulfill our choices.    However, "According to a 2004 poll conducted by Ipsos-Reid on behalf of the Canadian Hospice Palliative Care Association and GlaxoSmithKline, 80% of Canadians agreed that people should plan for the end of life when they are healthy – and yet 70% of them had not done so themselves." (quote from "How would you answer these questions? " By Sharon Baxter, Executive Director, Canadian Hospice Palliative Care Association, Speak Up article) [Note: the March 2012 Ipsos-Reid study, on the same issues, shows little difference in the past 8 years see Speak Up.]  

"According to the study, 65 percent of the doctors (or former medical students) had created an advance directive, i.e. a set of legal documents spelling out in advance what sort of end-of-life care they would like.  Only about 20 percent of the public does this.   When asked whether they would want .. CPR, if they were in a chronic coma, about 90 percent of the Johns Hopkins doctors said no.   Only about 25 percent of the public gives the same answer."

From article "Doctors Really Do Die Differently
Research Says That More Physicians Plan Ahead, Reject CPR, and Die In Peace
"
— based on John Hopkins Precursors Study by Ken Murray, MD, Clinical Assistant Professor of Family Medicine at USC

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Questions and Answers about Advance Directives

1) What is an Advance Directive?    An Advance Directive is a record of your values and directives/choices — in terms of general and/or specific medical care — for when decisions need to be made about 'extreme measures' treatment or terminal illness care.  It is only used if you become mentally incapable or otherwise unable to communicate your choices: until then, you retain the right to make all medical choices for yourself.   The Advance Directive must be written while you are still mentally capable — therefore, it is important to do so before major medical problems arise.   It is your voice when/if you can no longer communicate coherently or make considered decisions.

Please note:
    a.   In some provinces/territories, it is not required that Advance Directive choices be actually written down.   However, given the complexities of both our modern world and medical intervention — and especially if you have specific or detailed choices — we advise that your Advance Directive be both written and witnessed.   This avoids any confusion or misinterpretation if you are no longer able to communicate your choices or make considered decisions, and if the Advance Directive is required to determine further treatment.    In B.C., for example, an Advance Directive has recently become a legal written document, which must be followed by medical staff if available.    However, to be legal, it must be signed by 2 witnesses.
      b. If you have not addressed all major possibilities in your Advance Directive — and one arises — then decisions on treatment will be made by your Representative/Proxy or substitute decision maker.   Therefore, it is wise to use a comprehensive Advance Directive template that brings up a wide variety of possible issues that may arise — and discuss them in detail with your Representative, to give them some idea of what your wishes might be in unforeseen circumstances.    The 'table of contents' of the CINDEA-recommended Advance Directive is available here as a PDF download.

 

2) What is the value of having an Advance Directive?     It ensures that your values and directives/choices are known to your medical practitioners, family and friends; and are recorded clearly, to limit any bias in their interpretation.   An Advance Directive is most important when family members
        live at a distance,
are themselves not entirely mentally or emotionally capable (or likely to be when needed),
        do not share the same values, or
are not able to discuss end-of-life issues,
and/or when the person's choices are very specific (such as when to withhold or withdraw life-support).  
 
Even when this is not the case, Advance Directives may remove much of the confusion that can happen, as families struggle with unforeseen medical decisions on behalf of the 'incapable' member — as well as the potential guilt for the decisions made, especially concerning withholding or withdrawing life-support.   Romayne Gallagher, a physician, and founding director of the division of palliative care at the University of British Columbia. "Most people find if they have some idea what their loved one had in mind, it makes a difference." .. research clearly shows that discussing and planning your death means your wishes are more likely to be followed.   As well, family members experience less anxiety and depression in the aftermath, and report that the process is less agonizing....When families don't know the wishes of a loved one, they almost always default to more aggressive treatment - and often end up regretting the decision, says Daren Heyland, an intensive care physician.... (Quote from the Globe and Mail 'end of life' series, November 27, 2011 why are we afraid of talking about death by Erin Anderssen)



3) Is having an Advance Directive absolute assurance that your wishes/choices will be followed?    No — because of unforeseen medical circumstances, or new treatments available; or because the Advance Directive may not be available in some emergency situations.   However, most palliative-care or hospice organizations recommend having one (and it may be required upon entry into residential care); and as a result, more medical staff are honouring them.   If it is not possible to follow the specific choices of your Advance Directive, it will then be used to understand your values and apply them to the decisions that need to be made in that situation.   

Please note: although the use of Advance Directives is growing, some medical practitioners are unfamiliar with them, and may mistake them for a 'Do Not Resuscitate' order — which is only one option included in an Advance Directive, and one which you may not have chosen.   In any case, it is wise to review your Advance Directive with any doctor — or other medical staff — primarily involved in your care, to ensure that they understand your wishes if/when you are not able to communicate for yourself.

One person's choice

The only people in BC (and perhaps other provinces/territories) who are not required to abide by an Advance Directive are paramedics — as it is not likely that it would be immediately available to them, in an emergency situation.   However, if they know there is a "No CPR" order, they will not resuscitate.

The more usual ways of informing the paramedics are a medical alert bracelet, a wallet card (kept with the driver's licence), or a "No CPR" order on the fridge door.   One person has chosen the option to tattoo it into her skin in locations that the paramedics are unlikely to miss.
      

"No CPR" tattooed
over her heart
    

"DNR" (Do Not Resuscitate)
tattooed on right wrist, where paramedics would look for a
medic alert bracelet

 

4) Is an Advance Directive a legal document?   Yes, under common law — except for Nunavut, Nova Scotia, New Brunswick and Quebec (which, as of August 2011, have no legislation about Advance Directives, or are in the process of changing it) — although it does not have to be signed by a lawyer.   If you have an Advance Directive, your Representative/Proxy or substitute decision maker may be legally bound to follow it (or advocate for it with medical personnel). [Note: an Advance Directive has become a legal document in itself, in B.C.   It may also be a legal document — under a different name — in other provinces/territories.]

5) What is the difference between an Advance Directive and Expressed/Personal-Care Wishes?    An Advance Directive contains instructions on medical care including the withdrawal or withholding of care to allow a natural death to occur.   An expressed wishes/personal care document contains instructions or suggestions on non-medical matters including personal care, vigils, memorials, where you want to live, etc.

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Questions and Answers about Representation/Health Proxy Agreements

6) Who makes medical decisions for you if you can't?    Generally there are two options — a Representative/Proxy or a substitute decision maker.   If there is no Representative/Proxy, or the family is arguing over who will make the decisions, then the courts will appoint a legal guardian, which can become a very lengthy and expensive process — and the family or the estate will be charged for the cost.

A substitute decision maker is a default option if there is no designated Representative/Proxy.   Each province or territory has a list, in a prescribed order, of family members who can act as substitute decision maker — generally spouse, adult children (by age), parent, sibling, and finally other family members by birth or adoption (and in some provinces, close friends).   A substitute decision maker will be chosen for you (without your consent, if you are not 'capable') if you have not designated a Representative, and/or if your family does not agree as to who will act as the substitute decision maker.   [Note: by law, a substitute decision maker cannot be a family member who is in dispute with you or has not had regular contact with you.]

7) What is a Representation/Proxy Agreement?    It is a document that designates your Representative(s) and defines their responsibilities.   There are two types — and unless you are comfortable with the default substitute decision maker that would be chosen for you, it is wise to choose the second type.

a.   Standard Health and Personal Care Powers — which only deals with 'personal care' and minor medical decisions (as well as, possibly, regular finances — bills and bank accounts), and does not cover major medical decisions.
b.   'Enhanced' or 'Additional' Powers — which does include the right to make major medical decisions (such as withholding or withdrawing life-support), in addition to the medical decisions covered by the standard agreement, but generally does not cover finances.

Please note: both these kinds of agreements may have different names and/or conditions in your province/territory.   See our Resources in Canada Pre-death page section on Advanced Care Planning Resources for specific information in your area.


8) What is a Representative/Proxy/Health Agent?    This is someone who is specifically designated by you, in a written and witnessed document, to make medical decisions for you when you can't (although they may also support you while you still can); and who is legally bound to advocate for the choices in your Advance Directive, if one exists.   This may be a family member (should you wish to designate someone who is not the first on the substitute decision maker list) or a close friend.   A Representative should be chosen in any situation where you have concerns about the ability of particular family members to understand and/or follow your choices (whether or not you have an Advance Directive), or when there are no family members available to take this role.

It is wise to name at least a primary and an alternate Representative (or co-Representatives, but define how they make collaborative choices) — if not a 'default Representative' as well (which can be a faith community).   The default Representative will be called on to act in case of unforeseen circumstances where your primary and alternate Representatives cannot serve.   It is recommended that the Representatives NOT be the same as your power of attorney (who deals with financial and legal decisions while you are still alive i.e. not your executor, although you might name the same person to hold both roles of PoA and executor).   It is also recommended that the Representation Agreement NOT include regular financial/legal duties, unless your financial/legal matters are very simple and minimal (usually only included in a standard Representation Agreement).


9) Does a Representation/Proxy Agreement need to be signed by a lawyer?    In B.C., a 'Standard Health and Personal Care Powers' Representation Agreement does NOT need to be signed by a lawyer — and as of September 2011, an 'Enhanced or Additional Powers' RA also need not be signed by a lawyer.   You will need to check the laws for your own province/territory, as these may vary (check our Resources in Canada Pre-death page, the section on Advanced Care Planning Resources).


10) Which has more power — an Advance Directive or a Representation/Proxy Agreement?   Ultimately, your Representation/Proxy Agreement will have more power — due to the possibility of needing to making decisions that are not addressed in the Advance Directive; unforeseen medical options that become available; or if a situation arises where your wishes simply cannot be fulfilled.    However, if the Advance Directive is considered a legal document in itself, it will have at least equal power to a Representation/Proxy Agreement; and in many provinces, is equal to your own voice (i.e. more powerful than the Representation Agreement).

Many Enhanced Representation/Proxy Agreement templates give unlimited decision-making power to the Representative/Proxy and do not address the presence of an Advance Directive (even if the Representative is legally bound by it).   Although none of us would like to think of a family member or friend misusing this power, elder abuse is a growing problem.  [Note: if you have any concerns about elder abuse, please see our Resources in Canada Pre-death Page, section on Elder Law and Mediation CANADA.]

It is also possible that if your Advance Directive is not comprehensive and/or discussed thoroughly with your Representative/Proxy, they may misunderstand your wishes.   
Therefore, it is wise to ensure that your Representation/Proxy Agreement clearly defines the role as following/advocating-for your Advance Directive — as this will give more weight and clarity to your Advance Directive with your medical practitioners.

As an example, the Representation Agreement recommended by CINDEA includes the words, "…in accordance with my Advance Directive and expressed wishes… whenever and in all matters possible."

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Dementia and Advance Planning

Dementia, in particular, is a growing phenomenon.   Certainly, in earlier times, what was originally called "senility" was not uncommon; but because people didn't tend to live as long, the condition probably did not become as extensive as it is now.   The Alzheimer Society of Canada — in their recent study Rising Tide: the Impact of Dementia on Canadian Society — predicts that there are likely to be about 2.5 times as many cases of dementia by 2038 as there are now, with the cost of care increasing 10 times within a generation.   Other studies show that, "Of those with dementia, 60% live in developing countries, with this number rising to 71% by 2040."  [Quote from Randall Parker's Future Pundit blog on Total World Dementia.]  
 Furthermore, 1 in 3 Seniors Dies With Alzheimer's or Other Dementia

 

Air — remembrance flower mandala by Elli Boray

Except perhaps in the later stages, it is quite possible for people with dementia to make decisions — but it becomes progressively difficult (from early stages on) for them to understand both the context of the decision and its consequences.   There is simply not enough memory or cognitive power — and decisions tend to be made on immediate emotional reactions (for example, refusing to take a bath, without any understanding of the personal repercussions to one's health)

An Advance Directive, for a person with dementia, can be both a blessing and a curse.   It can be written in the very early stages of dementia (when it is only short-term memory that is being primarily affected) — but not afterwards, as it becomes less possible for them to consider the ramifications of the possible choices.   Unfortunately, in later stages of dementia, the person may have no memory of writing it, and is likely to state immediate wishes that are directly contrary to it.   However — especially if the Advance Directive includes dementia provisions (a statement of wishes, should the writer move into dementia, and according to different stages of the disease) — their Representative/Proxy or substitute decision maker will have the guidance of their 'written voice' as to what major medical decisions to make, according to their considered choices when fully mentally capable.  


Dementia is a progressive disease, often described as a journey along a winding pathway.

  Quote from On the journey, from the Dementia Journey website (which no longer exists, but the Alzheimer Society of B.C. carries most of its information).

Dementia is a very difficult disease to handle — both for the person with dementia and their caretakers (professionals and family/friends) — as the person's personality changes considerably, and sometimes becomes unrecognizable or the extreme of earlier traits.   If the Advance Directive also includes a thorough review of personal-care preferences (Expressed Wishes), this can help in understanding immediate/emotionally-based wishes; and may avoid unnecessary negative reactions, that might eventually lead to a breakdown in caretaking — such as not being able to keep them at home any longer.   For example, a simple note in the expressed wishes — "I don't like yellow" — may explain the resistance to wearing a certain piece of clothing.

A comprehensive Advance Directive and Representation/Proxy Agreement is, perhaps, the only way that a person with dementia's own voice — their considered choices — remains in place, able to guide the very difficult responsibility of making specific choices for them in a particular time/situation, especially when it comes to major end-of-life decisions.     [See also the Dementia Resources section on the Resources in Canada — Pre-Death page.]

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Advance Planning
for the Pan-Death Process
 

Summer — remembrance flower mandala by Elli
Boray
 
The options for alternative medical care, personal care, the pre-/during/post-death stages, and burial/cremation are expanding, as
    our culture becomes more multi-cultural (whether ethnic or lifestyle variations);
medical options are constantly being updated and/or added;
natural/ecological alternatives are considered; and
personal values change.
 
However, at the end of life, it may not be possible to thoroughly evaluate all of these options.   The death journeyer no longer has the same energy to consider options, or may be incapable of doing so.   Also, the family or caregiver(s) need to focus entirely on caregiving, plus other drains on their energy and time, such as:
  anticipatory, ambiguous and/or disenfranchized grief;
  financial worries;
  dissention in the family over who should be giving the care and what the care should be;
  simple exhaustion, especially after a long period of caregiving; plus
  upcoming legal concerns over wills, etc.

Therefore, we strongly encourage people to research and consider their choices, while they are still reasonably healthy and well in advance of any serious medical condition (accident, stroke, etc.) or the worsening of a chronic condition, which may then become life-threatening.    Remember: any of us — no matter what our age — could have an accident or a sudden illness, that would compromise our ability to communicate our wishes.

The variety of matters to consider is described on various pages on this site, but below is a quick review of them.   Some of these may not be relevant to a particular person.    However, for all those that are relevant, it is important to discuss them with the family/friends well beforehand, so that they are familiar with the choices you wish to make.

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Options to Consider

Senior/end-of-life/Advance Planning consultants These practitioners can help you navigate the options, understand their consequences, and create a comprehensive plan.   See CINDEA's Resources pages — Pre-death, Post-death, and Resources Elsewhere (outside of Canada) — especially the Death Midwifery and related services and EOL Advance Planning resources sections.
Hospice/palliative care

We recommend you look at these two sites and consider the issues they bring up.

  Canadian Hospice Palliative Care Association (which includes a directory of Provincial Hospice/Palliative Care organizations, under "Provinces")
  Canadian Virtual Hospice (a wide variety of information on end-of-life concerns, and information on Advance Planning in each province/territory under "For Professionals", then "Tools for Practice", then "Advanced care planning / Decision making", which has 7 pages of material a huge resource)
 
Support from death doula or death midwife, palliative-care teams and hospice volunteers, etc., on life stories,  'self-aware dying' support,  appropriate visitation,  alternative therapies for comfort care,  family or professional caregiving support,  anticipatory grief.
Pre-death Support from death midwife, home funeral guide, funeral celebrant, or clergy on initial plans for the funeral or memorial service — with the death journeyer being directly involved if they so choose.
Dementia

It is very important to have some sort of dementia provision in the Advance Directive;, and to have a Representative or a substitute decision maker who will be capable of making decisions based on your values, in case of dementia.

During dying/death Death vigils or other forms of religious/spiritual support (including living/pre-death 'Celebrations of Life');  bedside singing;  aromatherapy;   attention to mouth care (ice chips/ointment) because the mouth becomes dry and painful at this time;  holding the death journeyer's hands and/or gently stroking their head and perhaps other parts of the body;  any other care that might contribute to physical or emotional comfort during the dying experience.
Immediately post-death Organ donation; funeral-home services; family-based/at-home post-death care (support from death midwives or home funeral guides for a home funeral);  lying-in-honour or wakes
Funeral choices Traditional burial;  green burial;  hybrid burial (partially green);  cremation;  plus newer, more ecological options to cremation — promession/cryomation (freeze-drying — not available in Canada yet);  resomation/aquafication (use of water, heat, and lye to reduce the body to an organic residue — soon to be available in Toronto and perhaps elsewhere see our Resources in Canada page, section on Additional Natural/Green-Friendly Options for the Remains).
Final ceremonies Funeral service; service at graveside or before cremation; memorial; obituary; on-line memorial/guestbook.





Last updated July 2015   © CINDEA  (To use more than a brief extract, please contact us for permission.)