Medical Directives: Expressing One’s Wishes and Ensuring They are Respected
By Michèle Sirois, collaborator at the Institut universitaire de gériatrie de Montréal (geriatric institute) and host of the Ère Libre show on MAtv
No one likes thinking about the end of their life or being incapacitated due to an illness or accident. While we can’t control what tomorrow will bring, in Quebec, there are several documents we can use to make sure our wishes are respected if ever we are unable to speak for ourselves.
The Institut universitaire de gériatrie de Montréal’s AvantÂge program had the brilliant idea of bringing together two experts in the field to inform us and reassure us on the topic. During a public lecture in the Le Groupe Maurice amphitheatre, Dr. Yvette Lajeunesse(1) and notary Me Yves Lambert(2) presented, among other things, the Protection Mandate and Advance Medical Directives. We left the talk better informed of the advantages and limitations of each document.
First, Dr. Lajeunesse, who had a lengthy long-term care practice, strongly recommended that everyone put down their wishes in writing. The spoken word may be forgotten, but the written word is in black and white. By filling out an official document, we are assured of the type of care we want or do not want to receive if ever we are incapacitated. It also prevents a great deal of worry, guilt and even conflicts among loved ones who might otherwise have to make the difficult decision for us.
Formerly called Mandate in Case of Incapacity, the Protection Mandate is used to indicate what type of care we wish to receive and how we would like our affairs managed in the event that we are unable to speak for ourselves. Of course, we have to fill out the document while we are still of sound mind and it will only take effect if ever we become incapacitated.
Me Lambert reminded us of the legal definition of incapacity: the inability to care for oneself or administer one’s property. We were not surprised to learn that cognitive disorders are one of the four most common causes of incapacity.
What it contains
The Protection Mandate lets you name one or more mandataries, of legal age, who will make sure that your wishes are respected. If you wish, you can appoint one person to administer your property and another to manage your care.
The form also has a space in which you can indicate your wishes regarding choice of housing.
There is a section entitled “End-of-Life Wishes,” in which you can oppose all forms of aggressive medical care. Finally, you can check a box to indicate other details and wishes you want carried out in an end-of-life situation.
How to fill out the form
While the eight-page form is quite simple to fill out, Dr. Lajeunesse warns us that writing out one’s wishes is not something you do on a whim. It’s important to examine your values, beliefs and concept of life and death before reaching a decision.
There are two ways to complete a Protection Mandate: before a notary or before two witnesses of legal age who are not named mandataries in the document.
Two conditions need to be met for the mandate to take effect:
- The person who filled out the mandate must be declared incapacitated by health care professionals (a social worker and a doctor).
- The mandate must be homologated by a notary regardless if it was signed before a notary or before witnesses.
For a free copy of the Protection Mandate, click here.
You can also purchase a paper copy for $9.95 in accredited bookstores.
Advance medical directive or AMD
The second document the speakers brought to our attention is the Advance Medical Directives (AMD) form. The directives are one of the three components of an Act Respecting End-of-Life Care. Me Lambert pointed out that the act covers palliative care as well as medical aid in dying.
Since 2015, every Quebec resident who is of age can use the Advance Medical Directives to express their wishes in three very precise end-of-life situations:
- “If I am suffering from a serious and incurable medical condition.”
- “If I am in a coma that is deemed irreversible or if I am in a permanent vegetative state (e.g. after a stroke)”
- “If I have severe dementia, with no possibility of improvement (e.g. advanced-stage Alzheimer’s-type dementia or other type of dementia).”
The person filling out the form must consent to or refuse five treatments for each situation:
- Cardiopulmonary resuscitation
- Ventilator-assisted breathing
- Forced or artificial feeding
- Forced or artificial hydration
All other wishes not included in the form can be expressed elsewhere, such as in a Protection Mandate.
What is the advantage of having Advance Medical Directives? The form is filed with the Régie d’assurance maladie du Québec (RAMQ). All doctors in Quebec have access to the information via a code. If you are ever incapacitated, the medical staff can know your wishes in the above situations.
Also the AMD takes precedence over all other documents, including the Protection Mandate. If you fill out both forms and your wishes contradict one or more of the medical situations mentioned in the AMD, it is the Advance Medical Directives that will be respected. Dr. Lajeunesse said that doctors are required by law to respect their patients’ AMD.
How to fill out the form
You can obtain a free online copy of the advance medical directives form at http://www.ramq.gouv.qc.ca/en/citizens/health-insurance/advance-directives/Pages/advance-medical-directives.aspx or by phone at:
- Québec City 418-646-4636
- Montréal 514-864-3411
- Elsewhere in Quebec 1-800-561-9749
This form is also easy to fill out, but requires some thought. As with the Protection Mandate, before returning the AMD to the RAMQ, it must be signed by two witnesses of legal age.
A notary can also handle all this for you.
Dr. Lajeunesse and Me Lambert stressed the importance of regularly reviewing these documents, especially when there are changes to our state of health. We may change our minds about the care we wish to receive or not receive in such situations. We can amend our wishes in these official documents at any time, provided we are still of sound mind.
The two speakers also recommended keeping one or several copies of these forms and making them accessible to our loved ones and our doctor.
Me Lambert informed us that the Protection Mandate and the Advance Medical Directives cannot include a wish to receive medical aid in dying. To receive this ultimate care, several specific conditions must be met and a separate form must be filled out.
(1) Yvette Lajeunesse, retired doctor, provided long-term care at the Institut universitaire de gériatrie de Montréal for 30 years. She teaches ethics to undergraduate students in Université de Montréal’s Faculty of Medicine, is a member of the Conseil des médecins du Québec’s ethics committee and is a doctoral student in philosophy.
(2) Me Jean Lambert, notary, helped develop the Act Respecting End-of-Life Care, serves on the Commission sur les soins de fin de vie du Québec and gives lectures.