A Canadian Advance Healthcare Directive (commonly called a Living Will) is a legal document in which a capable adult expresses their wishes regarding healthcare treatment in advance, to be followed if they become incapable of making or communicating their own healthcare decisions. Unlike a Last Will and Testament, which takes effect upon death, an Advance Healthcare Directive operates during the person’s lifetime — specifically, during any period of incapacity.

Canadian healthcare decision-making legislation is a provincial matter, and the terminology and legal framework vary significantly across provinces. In Ontario, the primary instrument is the Power of Attorney for Personal Care under the Substitute Decisions Act, 1992 (S.O. 1992, c. 30), which appoints a substitute decision-maker (called an Attorney for Personal Care) and may include instructions about the person’s wishes. The Health Care Consent Act, 1996 (S.O. 1996, c. 2, Sch. A) establishes the framework for healthcare consent and requires substitute decision-makers to follow the person’s prior capable wishes (s. 21(1)). In British Columbia, the Representation Agreement Act (R.S.B.C. 1996, c. 405) allows individuals to appoint a Representative to make healthcare decisions, with two types of agreements: a section 9 agreement (limited powers) and a section 7 agreement (broader powers including refusal of life-sustaining treatment). In Alberta, the Personal Directives Act (R.S.A. 2000, c. P-6) provides a comprehensive framework for advance directives, allowing individuals to appoint an Agent and to give specific healthcare instructions.

The Directive typically covers five critical areas: life-sustaining treatment (mechanical ventilation, dialysis, vasopressors), cardiopulmonary resuscitation (CPR/DNR orders), artificial nutrition and hydration (tube feeding, IV fluids), pain management and palliative care (including palliative sedation), and organ and tissue donation. The document should also address the appointment of a healthcare proxy, the proxy’s authority, and the hierarchy of decision-making if the proxy is unavailable.

Every Canadian adult should have an Advance Healthcare Directive, regardless of their current health status. Unexpected illness, injury, or cognitive decline can occur at any age, and without a directive, healthcare decisions will be made by substitute decision-makers following the provincial statutory hierarchy — which may not reflect your personal wishes. In Ontario, the Health Care Consent Act (s. 20) establishes the following hierarchy: (1) the appointed Attorney for Personal Care, (2) the person’s spouse or common-law partner, (3) an adult child, (4) a parent, (5) a sibling, (6) any other relative. If no one in the hierarchy is available, the Public Guardian and Trustee may become the substitute decision-maker.

An Advance Healthcare Directive is especially critical if you have strong preferences about end-of-life care, religious or cultural beliefs that affect medical treatment (such as refusal of blood transfusions), or if you wish to ensure that your loved ones are not burdened with making difficult decisions without guidance. The directive is also important if you wish to express your views about Medical Assistance in Dying (MAID), which became legal in Canada under Bill C-14 (2016) and was expanded by Bill C-7 (2021). While an advance directive cannot currently authorize MAID in advance (the person must have capacity at the time of assessment), it can indicate your awareness of MAID and your general wishes.

You should create this directive while you are mentally capable. If you later develop dementia, suffer a traumatic brain injury, or are in a coma, you will no longer be able to create or modify the directive. The directive should be reviewed periodically and updated whenever your health status, family situation, or treatment preferences change. Courts have held that prior capable wishes, when clearly documented, carry significant weight in healthcare decision-making (Cuthbertson v. Rasouli, 2013 SCC 53).

A comprehensive Canadian Advance Healthcare Directive must include several essential elements. First, clear identification of the Principal (Maker), including full legal name, date of birth, address, and provincial health card number. Second, a declaration of capacity — confirming that the Principal is an adult of sound mind who understands the nature and consequences of the directive.

Third, the appointment of a Healthcare Proxy (Attorney for Personal Care in Ontario, Representative in BC, Agent in Alberta) with defined authority to make healthcare decisions, access medical records, and enforce the directive’s instructions. The proxy should not be a person disqualified under provincial legislation — for example, in Alberta, the witness cannot be the agent or the agent’s spouse (Personal Directives Act, s. 5(2)), and in Ontario, the attorney cannot be the owner or operator of a residential care facility where the grantor resides (Substitute Decisions Act, s. 46(2)).

Fourth, specific healthcare instructions covering: life-sustaining treatment preferences, CPR/DNR directives, artificial nutrition and hydration, pain management and palliative care, and organ and tissue donation. These instructions should be detailed enough to guide healthcare providers but flexible enough to account for unforeseen circumstances. Fifth, a MAID acknowledgment — clarifying that the directive does not constitute a MAID request but may express the person’s awareness of the option. Sixth, a revocation clause confirming that the Principal may revoke or amend the directive at any time while capable. Finally, the proper execution formalities: the directive must be signed by the Principal and witnessed in accordance with provincial requirements (two witnesses in Ontario under the SDA, one witness in Alberta under the PDA), with appropriate restrictions on who may serve as a witness.