Advance medical directives

Notice

The Act respecting end-of-life care was passed on June 5, 2014 and sanctioned on June 10, 2014. The provisions of the Act set out on this page came into force on December 10, 2015.

Advance Medical Directives in Case of Incapacity to Consent to Care form extracts

The Advance Medical Directives in Case of Incapacity to Consent to Care form is divided into 3 different sections:

  • Section 1 includes general information
  • Section 2 specifies your advance medical directives
  • Section 3 includes the required signatures

For information purposes only, this page presents the contents of section 2 of the form, which is the main part containing your advance medical directives.

Important notice

  • You may not use this section to prepare your advance medical directives. No copy printed from this page will be accepted by the Régie de l'assurance maladie du Québec (RAMQ) or by a health-care professional. Only advance medical directives given on the personalized form received from the RAMQ, duly completed and signed will be valid.
  • If you want to properly complete your advance medical directives, please refer to the Procedure section.

Section 2 – My Advance Medical Directives (excerpt of the Advance Medical Directives in Case of Incapacity to Consent to Care form)

This section cannot be printed. To obtain the form, consult the Procedure section.

The consent to or refusal of care that you express in this section will apply only if you become incapable of giving consent to care and if the care mentioned in the situations below becomes medically appropriate.

These clinical situations are increasingly common and are situations in which the relevance of certain care may be questioned, even if the care is required to sustain life. Capable individuals may decide in advance whether they consent or do not consent to having the care provided, should they become incapable of giving consent to care.

IMPORTANT : The items of care mentioned below are vital treatments. As a result:

  • Not accepting the care or terminating the care may reduce your lifespan.
  • Consenting to the care may prolong your life, with no hope of improving your medical condition.

Whatever you choose, you will be given the care needed to ensure your comfort, such as for pain management.

These directives do not influence the measures to temporarily maintain vital processes which are needed for organ donation, in the event you have consented to that.

For each item of care, check the box (one only) that corresponds to your wish, should the care become medically appropriate.

End-of-life situation

If I am suffering from a serious and incurable medical condition, and I am an end-of-life patient

Care A

□ I consent to cardiopulmonary resuscitation.
□ I refuse cardiopulmonary resuscitation.

Care B

□ I consent to ventilator-assisted breathing or breathing assisted by another device.
□ I refuse ventilator-assisted breathing or breathing assisted by another device.

Care C

□ I consent to dialysis treatment.
□ I refuse dialysis treatment.

Care D

□ I consent to forced or artificial feeding.
□ I refuse forced or artificial feeding.

Care E

□ I consent to forced or artificial hydration.
□ I refuse forced or artificial hydration.

Situation in which cognitive functions are severely and irreversibly compromised

If I am in a coma that is deemed irreversible or if I am in a permanent vegetative state

Care A

□ I consent to cardiopulmonary resuscitation.
□ I refuse cardiopulmonary resuscitation.

Care B

□ I consent to ventilator-assisted breathing or breathing assisted by another device.
□ I refuse ventilator-assisted breathing or breathing assisted by another device.

Care C

□ I consent to dialysis treatment.
□ I refuse dialysis treatment.

Care D

□ I consent to forced or artificial feeding.
□ I refuse forced or artificial feeding.

Care E

□ I consent to forced or artificial hydration.
□ I refuse forced or artificial hydration.

Other situation in which cognitive functions are severely and irreversibly compromised

If I have severe dementia, with no possibility of improvement (e.g., advanced-stage Alzheimer’s-type dementia or other type of dementia)

Care A

□ I consent to cardiopulmonary resuscitation.
□ I refuse cardiopulmonary resuscitation.

Care B

□ I consent to ventilator-assisted breathing or breathing assisted by another device.
□ I refuse ventilator-assisted breathing or breathing assisted by another device.

Care C

□ I consent to dialysis treatment.
□ I refuse dialysis treatment.

Care D

□ I consent to forced or artificial feeding.
□ I refuse forced or artificial feeding.

Care E

□ I consent to forced or artificial hydration.
□ I refuse forced or artificial hydration.

Last update: May 24, 2017 3:35 PM

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