Advance Care Directives in Ontario

A retired nurse in Etobicoke completes a clear written statement: she does not want CPR, intubation, or artificial nutrition if she is in an end-stage terminal condition. She gives a copy to her daughter, who is her attorney for personal care, and to her family doctor. Two years later she has a sudden cardiac event in a Mississauga restaurant. Paramedics begin CPR; her daughter arrives at the hospital with the POAPC in hand and explains the wishes. The ICU team confirms with the daughter that the wishes apply to the current circumstances. Treatment is withdrawn, and she is allowed to die without further intervention. The system worked because the right documents were in place and the daughter knew exactly what to say.

That outcome is what Ontario's advance care planning framework is designed to produce — substitute decision-making by someone who knows your wishes, backed by a statute that requires those wishes to be followed. The Ontario framework does not use a separately-defined "living will" document, which causes endless confusion. It uses two pieces of legislation working together.

This guide explains how the Ontario system actually works in practice. For wider context see our estate planning pillar and the is-my-POA-valid-in-all-provinces article for what happens when you cross provincial borders.

The two statutes #

Ontario regulates substitute decision-making for personal care through two statutes:

• The Substitute Decisions Act, 1992 governs the creation, scope, and termination of Power of Attorney for Personal Care (POAPC) and the appointment of guardians of the person.^[1]
• The Health Care Consent Act, 1996 governs informed consent to treatment, admission to care facilities, and personal assistance services. It also sets out the default hierarchy of substitute decision-makers and the rules they must follow.^[2]

Together they answer two distinct questions. Who decides? (POAPC + SDM hierarchy under HCCA.) And on what basis? (The HCCA rules requiring SDMs to follow prior capable wishes or, failing those, to act in the incapable person's best interests.)

What a POAPC does #

A POAPC is a document signed while you are mentally capable that names one or more attorneys to make personal-care decisions on your behalf if you become incapable. Personal care covers:

• Healthcare (consent to or refusal of treatment, including life-sustaining treatment)
• Nutrition and hydration
• Shelter (where you live, including admission to a long-term care home)
• Clothing
• Hygiene
• Safety

The POAPC takes effect for a specific decision when you are assessed as incapable of making that decision — capacity is decision-specific, so you may remain capable of some choices while incapable of others. Common Ontario practice is to combine the POAPC with a written set of wishes, signed and dated, attached to or referenced in the document.

Execution requirements under the SDA: two witnesses present, both 18 or older. Certain people cannot witness the document — the attorney or the attorney's spouse or partner, the grantor's own spouse or partner, a child of the grantor, and anyone under court-ordered substitute decision-making. The attorney themselves does not sign the document.

The Health Care Consent Act SDM hierarchy #

If no POAPC exists, the HCCA assigns a substitute decision-maker from a statutory hierarchy.^[5] The highest-ranking available, capable, and willing person makes the decision. In summary the order is:

1. The guardian of the person (court-appointed)
2. The attorney for personal care under a POAPC
3. A representative appointed by the Consent and Capacity Board
4. The spouse or partner
5. A child of the person or a parent who has custody
6. A parent who has only a right of access
7. A sibling
8. Any other relative
9. The Public Guardian and Trustee (default, last in the line)

To be eligible to give consent at a given rank, the person must be at least 16 (unless they are the incapable person's parent), capable of making the decision, available, willing, and not under a court order prohibiting them from doing so. Family conflict at the higher ranks is common — siblings who disagree all rank equally and have to find consensus or one of them has to apply to the Consent and Capacity Board.

Prior capable wishes — the binding rule #

The single most important HCCA rule for advance care planning is that an SDM must follow the patient's prior capable wishes that apply to the circumstances. Specifically:

• The SDM must give effect to a wish expressed while the person was capable and 16 or older, if the wish applies to the actual decision and is possible to follow.
• Where multiple wishes have been expressed over time, the most recent applicable wish governs.
• Wishes can be in writing, oral, or expressed by any means the person used to communicate.
• Where the wish cannot be followed (it does not apply to the circumstances or it is impossible), the SDM acts in the person's best interests under the HCCA's best-interests test.

This rule is why a clearly-drafted, dated, written statement of wishes attached to a POAPC is so powerful. The attorney is not just trusted to do the right thing — they are legally bound to follow the wishes the patient expressed while capable.

What 'best interests' means under the HCCA #

When no applicable prior capable wish exists, the SDM is required by the HCCA to act in the person's best interests, taking into account:

• The values and beliefs the person held while capable, that the SDM knows about
• Any wishes the person expressed that do not apply directly to the decision
• Whether the treatment is likely to improve the person's condition, prevent it from worsening, or reduce the extent or rate of deterioration
• Whether the person's condition is likely to improve, remain the same, or worsen without the treatment
• Whether the benefit outweighs the risk of harm
• Whether a less restrictive or less intrusive treatment would be as beneficial

This statutory test is what protects against an SDM substituting their own values for the patient's. It is also why, in cases of family disagreement, the Consent and Capacity Board often becomes the forum where the best-interests analysis gets formally tested.

Common practical mistakes #

A few patterns that come up repeatedly:

• No written wishes at all. The POAPC names an attorney but contains no specific guidance. The attorney is then forced to guess or to apply their own values. Even a one-page typed statement of wishes makes a meaningful difference.
• Wishes that are too vague. "I don't want to be kept alive on machines" is hard to apply when the question is whether to start CPR or to continue ventilation that has already begun. Specific scenarios (irreversible coma, end-stage dementia, terminal illness with prognosis under six months) are more useful than general aspirational statements.
• Naming two attorneys who must act jointly without a tie-breaker. Joint attorneys must agree; a tie blocks action in the middle of an emergency. Naming one primary and one alternate, or three with a majority rule, avoids deadlock.
• The POAPC sitting in a safe deposit box. The attorney can't use what they can't find. Copies should be given to the attorney, the family doctor, and any hospital with an active relationship.
• Wishes that have not been discussed with the attorney. A document the attorney has never read becomes a courtroom artifact. The conversation matters more than the document.

What we focus on at It's Simple Will #

It's Simple Will's primary product helps Canadians complete the will. Power of Attorney for Personal Care work is part of the roadmap; for now, the platform points Ontario users to province-specific resources like Advance Care Planning Ontario (formerly Speak Up Ontario), the CLEO POAPC publication, and provincial government materials for the formal POAPC document. The Life Discovery Kit captures the values and wishes information an attorney will need so the conversation has somewhere to live in writing.

For wider context see the estate planning pillar, the is-POA-valid-in-all-provinces article, and the wills pillar. Start your will at the It's Simple Will app.