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

10. Insert a clause providing that the document can be released to the healthcare team upon request, and provide a wallet card to signal the existence of a power of designated substitute decision-maker for personal care

While people who engage in advance care planning and write advance directives have usually spent considerable time and effort deciding what values, beliefs, and treatment goals are important to them, such values may still not be respected because the designated SDM doesn’t know that they exist, can’t find the document and/or doesn’t wish to follow its instructions as this would result in the loss of someone they love. The SDM may not be available at the time such information is needed, and healthcare teams are therefore challenged to anticipate what treatments the patient would want to undergo.

Further, if the designated SDM refuses to provide a copy of the power of attorney documents and directives, healthcare teams have no recourse to obtain them.15 In situations where concern has arisen that the designated substitute decision-maker is not meeting his or her legal obligations with respect to the standard of decisions, such documents could serve as a tool to first discuss any discrepancies and, if these couldn’t be resolved, would be needed in the adjudication of intractable conflicts.

Without a central registry for these power of attorney documents, it is difficult to know how these challenges can be consistently overcome. One practical step that is readily adoptable now is to create a wallet-size card for the client to carry upon his or her person (or even a medical alert bracelet, should this be more convenient) that declares the existence of advance directives and the law firm’s contact information in order that these may be retrieved upon receipt of a properly signed request.

While this will not prevent all unwanted treatments – for example, patients who do not wish to be may still find themselves resuscitated in an emergency situation if afterhours or on weekends – such an approach would still constitute a significant improvement over the existing process. In view of the importance that should and must be accorded to such documents and advance directives, it is crucial to provide ready access and availability to SDMs and healthcare teams.


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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