Your Substitute Decision Maker (SDM) is the person who will make health care decisions for you if a time comes when you are unable to speak for yourself.

Do you know who that person is?  Are you sure it’s the right person?

In Ontario, a health care provider can only take consent from a person, not from a document (such as an Advance Directive or Living Will). Ideally, that consent comes from you as the patient.  But, even if you are deemed mentally incapable to make the decision, a person still needs to provide consent on your behalf.  In Ontario, that person will be identified according to a hierarchy.

Often, we assume that our spouse or perhaps our eldest child is the obvious choice to make decisions for us and perhaps we have named this person in a Power of Attorney for Personal Care.  Sometimes, this is the best person, but sometimes it is not.

Here are a few things to consider:

  1. Will this person be able to make decisions about my care the way I would make them?

It can be difficult for an SDM to set aside their own wishes in favour of the known wishes of the patient.  Will your spouse or child be able to make the decision to allow a natural death or will they want to do whatever it takes to keep you with them as long as possible?  Do you trust this person to make the decision that you would make?  Families do not always agree on care and it important that your SDM feels confident to represent your wishes, even if there is conflict within the family and others disagree with the decisions made.

  1. Is this person reasonably available if they need to make many decisions?

In long-term care especially, there may be many health care decisions over a long period of time that require consent.  In addition to health care decisions, there will be decisions about nutrition, clothing, hygiene, and safety.   It’s a big responsibility and the SDM needs to understand that this isn’t just about making one decision and could require a significant amount of time and frequent contact.  Your chosen SDM should be easily reachable and have sufficient time to dedicate to decision making as needed.

  1. Have you reviewed your choice of SDM as your life changes?

If you name someone in a Power of Attorney for Personal Care, this document will trump the automatic family members in the hierarchy.  As your life changes, you will want to ensure that your choice of SDM is still the best person.  For example, if you name a spouse in your POA and subsequently divorce and remarry unless you revoke the original POA (or create a new one), the person named in the POA will trump the new spouse as your legal SDM.

Another consideration is potential changes to the mental capacity of the SDM.   The person who is your SDM must also be mentally capable, so if the capacity of your SDM changes over time, this can affect whether or not they are capable to make your decisions.  It can be prudent to name an alternate in your POA who can take over if your primary SDM becomes incapable.

Making health care decisions for a loved one is a big responsibility.  You will have greater peace of mind knowing that you have done what is necessary to choose the right person to make your health care decisions the way you would make them.

Written by: Dale Gellatly from Hospice Wellington

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