Estate Planning: Ten Practical Steps to Improve Written Advance Directives in Powers of Attorney for Healthcare

8. If appointing several substitute decision-makers for personal care, state how conflicts ought to be resolved with a view to decision-making

One of the most common challenges that occurs in the clinical context arises when more than one substitute decision-maker is appointed and either one cannot be reached in a reasonable amount of time (i.e. time at which point failure to make a decision without the other designated SDM risks compromising the care of the patient) or there is a disagreement regarding treatment choices. Estate lawyers would be well advised to insist that clients detail whether decisions can be made by one designated substitute if the other is unavailable or unwilling, or has lost her or his own capacity.

One of the most significant contributions to improving the advance care planning process would be to require a conflict resolution process should disagreements arise between the designated substitutes, either by directing that the decisions of one should prevail, creating a majority rule, or some such similar declaration. Such steps, if established a priori, could potentially avoid interpersonal hurt and breakdown of relationships if their rationale was explained and understood by all parties. Furthermore, such conflict resolution mechanisms may prevent treatment delays which may themselves adversely affect the patient’s outcome, as well as short- and long-term quality of life. Lastly, such mechanisms may prevent healthcare teams from engaging the Public Guardian and Trustee as decision-maker of last resort, a situation which the client may wish to avoid.

Go to Step 9

The author wishes to encourage and engage in discussion regarding the directives she proposes here. Please take a moment to express your thoughts and critical commentary in the comments section below.

About the Author


LAURA HAWRYLUCK received her MD in 1992 from the University of Western Ontario where she also served her Internal Medicine residency. She completed a Fellowship in Critical Care at the University of Manitoba in 1997 and received her MSc in Bioethics in 1999 from the Joint Centre for Bioethics and the Institute of Medical Science at the University of Toronto. From 1999-2001 she was Assistant Professor of Critical Care/Internal Medicine, Queen’s University, Kingston, Ontario. In March 2000 she was appointed Physician Leader of the national Ian Anderson Continuing Education Program in End-of-Life Care at the University of Toronto and is currently Associate Professor of Critical Care Medicine at the University of Toronto. In 2002, she was awarded the Queen’s Golden Jubilee Medal for contributions to Canada in recognition of her work in creating the Anderson Program and improving end of life care for Canadians. Dr. Hawryluck is co-author and editor of “Law of Acute Care in Canada” to be published shortly by Carswell, a division of Thomson Reuters.

Dr. Hawryluck is deeply involved in international humanitarian projects. She has worked with critical care and burn units in Indore India and Cote d’Ivoire on a variety of quality improvement and educational initiatives. She was co-creator and co-Director for RCCI of the first Doctorate in Medicine Program in Critical Care in the entire country of Nepal. She worked with the Nepal Medical Council as an international consultant to enact a Code of Ethics and Professionalism for all physicians in Nepal.

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