For health adults, an ACP conversation will be more hypothetical than for someone with a serious illness. 

Invite a person to visit the ACP Ontario website to learn more - on their own time and at their own pace.

• You do not need to ask about illness understanding.
• Many healthy people will have given little thought to concerns about end of life and will not be willing to discuss this at this point.
• Identifying an SDM and learning about Substitute decision-making may be the main focus for this person.
• Recognize that a healthy person may in fact be the SDM for someone else in their life, so ACP should be very relevant to them.

The point is to introduce the concepts of ACP and SDMs and to normalize them. These conversations will become more relevant as the person ages.

Individuals experiencing structural vulnerability face high morbidity and mortality, which necessities early advance care planning. 

• Consider how adverse social determinants of health will affect whether your patients’ wishes can and will be respected.
• Explore, anticipate and address potential barriers to care. 
• Explore social support networks and caregivers and actively involve them in care planning.
• Recognize that the healthcare system is a place where many people have and continue to experience trauma.
• Integrate harm reduction and trauma informed and anti-oppressive care into your practice.
• Meet people where they are at, be non-judgemental and prioritize their safety, choice and control.

Here is a good resources:

Stajduhar et al. Too Little Too Late: How we fail vulnerable Canadians as they die and what to do about it. U Vic Institute on Aging & Lifelong Health.

At the time of diagnosis of a progressive or serious illness, help people be prepared by introducing ACP. 

• ACP conversations will be an opportunity to discuss illness understanding and learning about living with the illness.
• This is a good time to start getting people aware of the progressive nature of their illness, before they are very sick.
• As this is earlier in the disease trajectory, you can titrate prognostic information to their level of readiness. 
• These patients may or may not be ready to discuss worries & fears about dying, but may be able to discuss worries and fears about future states of health.
• Questions can be answered when the patient feels ready to address them or as their illness progresses.

In advanced illness, ACP and person-centred conversations become very relevant.

As disease progresses, the likelihood of delirium or other complications increase. These episodes result in a temporary (or permanent) loss of capacity for decision-making. It is important to discuss this with people so they can be pro-active in learning who their SDM is and discussing their values, wishes, fears and worries.

In this group, illness understanding and information become even more important because there is more information about the likely trajectory of the illness and what decisions might be in the future. This means preparation can be more specific and might involve wishes, beliefs and preferences about specific treatments.

For example,  wishes and beliefs about specific treatments may enter the ACP conversation as patient may have had personal experiences (e.g. ICU admission, intubation, BiPAP etc.).

It is important to introduce the concept of ACP, provide information about ACP/SDMs, provide education about illnesses and to support conversations about a person's goals and values .  Find out how to introduce and facilitate ACP conversations here. 

People with intellectual disabilities, based on their capacity, can still participate in ACP. Even though they might lack the understanding of their illness trajectory, they still can express their values and beliefs and their SDM should be listening to that whenever possible. 

• Most people with intellectual disability can and want to talk about what is important to them and what they value.
• We should make all efforts to involve people in discussions and conversations about what matters to them. 

People who lack capacity for treatment decision-making can still express themselves and their SDM should be open to these expressions and opinions.

Remember too that capacity is treatment-specific  and time-specific.

• A person may lack capacity to make a treatment or care decision at one time but mentally capable at another time. 
• A person may lack capacity to make one treatment decision (living environment) but have capacity to make another treatment decision (treatment for hypertension).

For this population as well, we must remember to prepare SDM(s) for future decision-making. Preparing means:

• Ensuring they know their role as an SDM.
• Helping them gain good illness understanding and know what to expect in the future with the illness.

This preparation will make decision-maker less distressing in the future.

The Supreme Court of Canada has ruled that preferences of mature minors (children under the age of 16) must be given sufficient weight as they mature and demonstrate stability of values. 

• Even if they are not “adults”, children and mature minors can be encouraged to express wishes and values to help with decision-making when needed.
•  In Ontario there is no specific age of consent. As long as a person is able to understand and appreciate the situation and the potential treatments (i.e. they are capable), then that person can make their own healthcare decisions, regardless of their age

• A family centred approach is taken to help everyone understand the child/adolescent’s illness and what might be expected to occur in the future

•  Even when a child or adolescent is not capable, they should be included in the discussions about their healthcare as much as possible. Advance Care Planning in this population involves preparing the child or adolescent, as well as their substitute decision-makers (in most cases the parents) for future decision-making. 

 Learn more about ACP in the paediatric population

During any clinical encounter,  take the opportunity to check-in and ask: 

"I wonder if during our next visit, we might take a step back and talk about your (illness) overall?"

 "do you feel like you know enough about your illness and what to expect in the future?"

 "you seem concerned about feeling fatigued...it is common for someone to get weaker over time with this illness...can we spend some time talking about what is happening?

 "this is a good opportunity to take a step back and talk about your health and what you might expect in the future...what do you think?"

"how is your family dealing with the changes in your health?"

"how are you managing with the changes in your health?"

• is discharged from hospital
• has a specialist visit
• has decreasing functional ability
• has an advanced chronic or life-limiting illness
• is 65 years of older
• is a resident of or about to enter long-term care
• is at risk of losing capacity to make treatment decisions
• does not have family/friend to act as SDM (therefore will one appointed through PG&T) 
  

You can also link ACP to other routinized practices such as routine chronic illness visits

• Revisit with any change in health or when a person's wishes, values or beliefs change.
• Revisions and updates must be communicated to the person's SDM(s).
• Any documentation of ACP conversations must be dated and should contain the most up to date information.

• Pay attention to cues and questions raised by patients/clients/residents.
• They are easy to overlook in a busy clinical setting, however, they are signals that people need more information or are looking for guidance and preparation.
• Notice the cues and questions and offer to discuss, even at a later date.