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

2. State what values, beliefs or outcomes the person wants to be considered with respect to initiating/continuing a treatment trial or withholding and withdrawing life-sustaining treatments and resuscitation

It is impossible to predict what the future holds in terms of a person’s state of health and potential treatment needs. What is known is that 70% of people will die in hospital, and almost all will be asked to consider if they would want a trial of life support and/or to undergo cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest or will have a discussion in which it is explained that such treatments, should they be needed, will not be offered given that they would not be able to help. Even if they are offered, such treatments come with no guarantee of success. Moreover, if a person survives critical illness, and is able to be weaned from life support, she or he is never the same, either cognitively or physically, as before. When engaged in estate planning, lawyers should encourage their clients to consider under what circumstances, if any, they would wish to undergo a trial of treatments and what they would wish their designated substitute decision-maker and healthcare teams to consider with respect to withholding or withdrawing such treatments.

Such advance directives should not seek to create an exhaustive list of situations. Rather, they prove most helpful in clinical practice if they outline values, beliefs, principles and treatment outcomes that would be considered acceptable (or not) to the patient. To provide an example:

“In all other situations, I direct that I would be willing to undergo a trial of resuscitation and life-sustaining treatments. However, if once these treatments are initiated it should become clear that I have lost and will not regain any ability to understand or process information and communicate in a meaningful way, I direct that life-sustaining treatments be withheld or withdrawn and that I receive treatments solely focused on palliative care.”

Go to Step 3


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

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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.