Picking the right power of attorney/substitute decision maker Dr. L. Shoots February, 2024 In Ontario, there are two different types of powers of attorney: power of attorney (POA) for personal care, and Continuing POA for property. The term ‘power of attorney’ is confusing, as it sounds very much like a lawyer in power, but what it really means is someone you are appointing to make certain decisions for you if you are incapable of making decisions for yourself. Another commonly used term is a substitute decision maker (SDM). There are two very key steps to POAs: 1. Naming someone to be your POA 2. Actually communicating with them in advance, what your wishes are in certain scenarios. Croak will help you with both. In Ontario, a POA for personal care is someone who will make decisions about your health when you are not capable too, per the Substitute Decision Makers Act, 1992. They will make decisions about your health care, nutrition, where you live, clothing etc. Again, remember, this is only if you cannot make your wishes for yourself. Naming a POA of personal care does not automatically give all of the power to this individual to make decisions for you, they only do so when you are deemed incapable by a professional, to make your decisions. This is why your POA personal care (herein we’ll just call it your POA) it’s an extremely important role, but also one that often creates a lot of stress for families when individuals have not properly communicated with their POA what their wishes are. Your POA must consider your wishes when they are making decisions for you, and this is why it’s so important to outline your detailed wishes in advance (often termed ‘advanced care directives’ or ‘advanced directives’). Saying ‘don’t make me a vegetable’ is definitely not enough (read our blog post about that here). It’s also important to highlight that a healthcare provider is unable to provide treatment if they are aware it goes against your wishes. On a similar note, a POA cannot demand treatment—it is up to the healthcare provider to decide what treatments are best for your loved one, and the POA can simply agree to decline the treatments offered. POAs also do not have to follow a wish that is impossible to honor. For example, if you wish to remain in your home and not be cared for in a healthcare institution, but your health requires it/other alternatives are not feasible, your POA may decide what the best place is for your needs. What happens if I become incapable and I have not legally named someone as my POA for personal care? Under the Ontario Health Care Consent Act (1996), you do not have to explicitly name someone as your POA. However, there is a legally determined hierarchy for who will automatically become your POA should you not officially name someone. For most people who do not have a legally appointed POA by court or by a document you have filled out (using our platform, a lawyer etc.), then their spouse/partner is automatically the POA. If you do not have a spouse, then it becomes your parents or children. See the image below for full details. It is also important to note that in an emergency, a physician can act as your POA. Are there certain people I cannot choose to be my POA for personal care? Do not appoint anyone that provides you with healthcare, or who you pay for services including your landlord (you pay rent too), your social worker, your counselor or teacher, your home cleaner, cook, or contractor. The only exception is if that person also happens to be your spouse/partner/relative. Also note that your POA must be over the age of 16. Can I have multiple POAs of personal care? You are allowed to name multiple people to be your POA, though we at Croak.ca do not encourage it. As our entire platform is about making lives easier for family, our founder's experience (a physician) is that when there are multiple people who are needed to make decisions, there is more room for conflict and indecision between them. Having multiple different people serve as your POA jointly can often create friction when opinions on how to handle a situation vary. Especially if the POAs are not good at communicating with one another, or if one does not want to make decisions without the other one being present. Sometimes this can lead to substantial delays, which can be a form of decision-making themselves in an emergency (sometimes making no decision, like choosing not to go for a substantial surgery until hearing from another POA, can cause an illness to progress to the point that now even harder decisions need to be made). The potential advantage of having multiple POAs is that if they are good communicators, they don’t have to feel alone in their decision-making. If you are interested in having multiple POAs, contact us directly and we will support you. Important considerations for choosing a POA: Here’s a list of things to consider when choosing a POA: How well do they know you? Do they have strong communication skills? Are they willing to ask questions, including difficult ones? Are they someone who knows what your current quality of life is like (they see you often, and understand your day to day abilities/limits? Do they live in the same community as you, and if they don’t, are they typically readily accessible in cases of emergency? Choosing a POA that doesn’t live near you (out of driving range/province/country) can pose challenges. One of the most obvious is that if you are being cared for by someone who does live near you, typically that person tends to have the best idea for your current health needs. This is a common source of friction between loved ones when a caregiver who has a thorough understanding of your day-to-day life is not named as the POA, but instead another loved one who lives farther away and doesn’t appreciate the nuances of your health. If you choose a POA that lives farther away, and especially if you choose a POA who is not your primary loved one taking care of you, you should ensure those individuals communicate well together and understand your state of health well. Lastly, it’s really important to talk with whoever you choose as your POA! Make sure they are comfortable with the role and understand your wishes. We also highly encourage you to share your wishes with all of your loved ones, to ease the role of your POA so everyone knows why they are making the decisions they are making. Losing a loved one is really hard on families, and if we can remove any of the preventable stressors beforehand, that’s what Croak is all about. Hop to it!

Feb 2024 Dr. L Shoots Summary: Most people associate the somewhat crass term of ‘being a vegetable’ with what some describe as a ‘vegetative state’: being artificially kept alive by breathing machines, feeding tubes, and medications, and being unable to walk, talk, or communicate in any meaningful way. It’s pretty universal that no one would like to live like this. So the much bigger questions come when your body is in a state that is not ‘vegetative’ but is nowhere near your normal level of functioning. What would you want then? That’s where Croak can help. When families have to make these health-related decisions, it is often the biggest source of conflict within families. Talking about it beforehand can help everyone to be on the same page and to make informed decisions with confidence. Communication with family members around their dying wishes is not an easy topic—we get that! One very common thing I hear as an emergency physician over and over again is that individuals think they have told their wishes to their loved ones when really all they’ve told them is ‘they would never want to be a vegetable’. Except it’s not nearly that simple. What actually defines being ‘a vegetable’? It sounds crass, but it is actually a really serious and important question. It’s probably pretty universal that the majority of people would not want to be artificially kept alive if they were in what many non-medical people describe as a ‘vegetative’ state—meaning they had no meaningful way to communicate, no way of moving any parts of their body, and were completely reliant on artificial sources to keep them alive (like breathing machines and tubes directly into the stomach for feeding etc.). This is why I hope we can all agree that telling your loved ones ‘you would never want to be a vegetable’ really isn’t that helpful. The vast majority of people feel this way! This is why you need to think deeper, and have much deeper discussions with whoever your power of attorney for personal health is, and provide them with much more detail 'advanced directives' to help guide their decision making when the time comes. For example, what about the individual who has had a massive stroke, and they can move their hand on one side of their body, and wiggle their toes on one side, but they still can’t talk or walk or eat after months of trying to regain function? What if they can open their eyes and look at you, but not communicate with you? What would they want then, if this was their permanent new state? Would they want to be kept alive, and new illnesses like pneumonia aggressively treated? Or would they want you to give doctors permission to keep them comfortable, and not treat new illnesses and let them pass away peacefully? What about a second scenario—you’re diagnosed with a terminal illness, but you’re still living your life to the fullest you can, still able to travel at this stage and enjoy time with loved ones—but then you suddenly go unconscious. Would you want aggressive therapy to try and bring you back to life, including putting you on a ventilator to breathe for you and putting you in a ‘medically induced coma’ so you can tolerate all of the treatments and tubes required to keep you alive? What if doctors said there was an extremely high risk that after initiating the treatment, we can’t actually bring you back to your previous quality of life and you may never be able to communicate normally again? Would your loved one want doctors to still try anyway? I could go on and on with examples. The decision to ‘not be a vegetable’ is easy. The much more difficult decisions lie in balancing someone's personal wishes and values—quality of life vs quantity of life. And those answers will be different for everyone. But the above examples are the kinds of high-stakes scenarios hospitals deal with every single day. And every single day patients’ power of attorney for personal care is asked to help guide physicians with what the patient would want in these types of scenarios. Many times, a legally defined POA does not exist and the default POA becomes the spouse. But it’s also not infrequent that we see a spouse who does not want to take on the role, or, who has children who are very vocal and trying to push certain decisions. So now there are multiple people, with multiple opinions, and the stress levels and conflict within families just rise substantially. It is also very common to see scenarios where the patient has not thoroughly expressed their wishes, and so the POA's decisions are questioned, and conflict between loved ones again occurs. In healthcare, we are very aware (from both longstanding evidence and lived experience) that this can be some of the biggest sources of conflict when families cannot agree on health-related decisions. This is why it is so important to talk about your health wishes in advance, well before your body is ever critically ill needing the hospital. Your loved ones need the ability to make informed decisions about what it is you would want, instead of guessing or having their decisions questioned by other loved ones. This is why we’ve created Croak. It’s meant to be a communication tool that allows you to easily share your wishes with all of your loved ones so everyone knows exactly what you want, and everyone is on the same page. Because it’s a digital platform, you can also do it from the comfort of your own home, and simply email your wishes to your loved ones and spare the awkward conversations. You can also use it as a conversation starter—whatever works best for you and your loved ones. All we care about is that you share your wishes with everyone, so that when the time comes, we all know what it is that YOU want!