Substitute Decision Makers

Health-care decisions if you can’t speak for yourself

You will always be asked to make decisions about your health care as long as you can understand information about your care options and can communicate your wishes. However, if you are too sick to make this decision and speak for yourself, you will need someone to speak to your health-care providers and make decisions for you. This is your substitute decision maker.

Choosing who would make future health-care decisions for you, if you can’t do it yourself, is a key part of Advance Care Planning.

Your expressed values, wishes and beliefs, like those expressed during Advance Care Planning, will help your substitute decision makers and health-care providers make decisions about your care that aligns with what matters most to you. Your substitute decision maker may also consult other people in your life to learn about what matters most to you and what care you would want.

About Substitute Decisions Makers

Duties of a Substitute Decision Maker

If a decision is needed and you have trouble understanding information, even with support, your substitute decision maker should still try to ask you about your wishes

As well as consulting with you to the greatest extent possible, your substitute decision maker must consider your previously expressed wishes or instructions when making a decision. If your substitute decision maker doesn’t know your wishes, they must make decisions they believe to be in your best interests.

  • your known beliefs and values.
  • whether your health is likely to be improved by the treatment.
  • whether your health is likely to improve without the treatment
  • whether the benefit of the treatment is greater than the risk of harm.
  • whether less intrusive care would be just as helpful to you.

How to choose a good Substitute Decision Maker

Your substitute decision maker’s role is to speak and advocate for you when you are unable to speak for yourself. They will provide consent for medical care or treatments and make sure your wishes are known. They must honour your wishes and instructions.

  • knows you well and understands your values, beliefs and wishes
  • will honor your wishes and instructions (this is their legal role), even if they are different from their own;
  • is calm in a crisis;
  • can communicate with health-care providers, advocate for you, and not be pressured into accepting treatment that they know you wouldn’t want;
  • can handle conflict or disagreement;
  • is willing and available to take on the role.

Think about who the best person is to speak for you.

Note: there is only one way to choose who your substitute decision maker is in BC – by appointing a Representative in a Representation Agreement .

Did you know?

Enduring Power of Attorney doesn’t cover health matters. The person you appoint in an Enduring Power of Attorney (Your Attorney) can take care of your legal and financial matters but can’t make health or personal care decisions for you.

When decisions need to be made

Your health-care provider will follow the steps below (which are required by the BC law) to find a substitute decision-maker for you when needed.

Substitute Decision Maker Hierarchy

The Steps in Details

If you are mentally incapable of making decisions for yourself and have no other legal documents in place, the BC Supreme Court may appoint a committee to make personal, medical, legal, and financial decisions for you. A committee is made up of one or more people (e.g., family member or close friend) or bodies such as the Public Guardian and Trustee of BC Once a committee is appointed, health-care providers must obtain consent from the committee.

It is usually a last resort in Advance Care Planning, as:

  • Appointing a committee can be a long and expensive process, difficult to reverse, and the individual loses their decision-making rights.
  • Once appointed, the committee must be the first people health-care providers contact to make decisions.

Learn more about committeeship on

Your Representative is a person appointed by you in a Representation Agreement to make personal and health-care decisions for you, if you can’t make these decisions on your own.

About Representatives

You can name one or more Representatives in your Representation Agreement. You can also name Alternate Representatives to act if your Representative can’t.

A Representation Agreement is a legal document, but you do not need a lawyer or notary to prepare a Representation Agreement.

See here for requirements for making a Representation Agreement.

Once you know who you want to be your Representative, talk to them and share your health-care wishes.

There are two types of Representation Agreements:

  1. A representative appointed by a Section 9 Representation Agreement
  2. A representative appointed by a Section 7 Representation Agreement
For more information on Enhanced Representation Agreements, see our three-part resource:
  1. What you need to know about enhanced representation agreements (section 9)
    English | Simplified Chinese | Traditional Chinese | Punjabi | Hindi
  2. What you need to know about being a representative in an enhanced representation agreement
    English | Simplified Chinese | Traditional Chinese | Punjabi
    | Hindi
  3. A guided tour of the BC government’s enhanced representation agreement (section 9) form.
    English | Simplified Chinese | Traditional Chinese | Punjabi | Hindi

An Advance Directive is a legal document that includes instructions from you to your health-care providers about specific treatments that you accept or refuse. These instructions are only used when you can’t make decisions for yourself, and there is no Representative appointed*.

About Advance Directives

An Advance Directive deals only with a specific treatment; do not record your general wishes or what matters most to you in life in an Advance Directive. You can record this information in an Advance Care Plan.

The instructions in your Advance Directive must be clear about the specific treatments you refuse or accept. See here for more information and other requirements for making an Advance Directive.

It is hard to cover every possible decision in an Advance Directive. If your Advance Directive is unclear or does not cover the specific situation you are in, your health-care provider will ask your Representative or Temporary Substitute Decision Maker for consent. Therefore, even with an Advance Directive, it is still important to consider who your substitute decision maker will be!

*If you have both a Representation Agreement and an Advance Directive

Your Representative will still be asked to make decisions, unless you state in your Representation Agreement that they should not be asked about decisions covered in your Advance Directive. Your Representative must still treat your Advance Directive as your wishes when making decisions.

Without a Representative or an Advance Directive, your health-care provider will need to identify someone to make those decisions for you. In health-care, this person is called your Temporary Substitute Decision Maker. The selected person is the first person to qualify as your Temporary Substitute Decision Maker on a list defined by BC law.

About Temporary Substitute Decision Makers

The list of potential Temporary Substitute Decision Makers is defined by BC law to make sure all British Columbians have somebody to make decisions for them if needed.

Your health-care provider can only move to a person lower down on the list if all the people above them are unavailable, unwilling or do not qualify.

A Temporary Substitute Decision Maker is NOT selected if you:

  • have appointed a Representative(Step 2) who is available and authorized to make the decision needed; and
  • have an Advance Directive (Step 3) that addresses the specific health care needed.

Temporary Substitute Decision Maker List

The first person on the list below who is willing, available and qualifies will be your Temporary Substitute Decision Maker:

  1. Your spouse (including common-law, same-sex, no matter how long you have been living together)
  2. Your child (equally ranked)
  3. A parent (equally ranked)
  4. A sibling (equally ranked)
  5. A grandparent (equally ranked)
  6. A grandchild (equally ranked)
  7. Anyone else related to you by birth or adoption
  8. A close friend
  9. A person immediately related to you by marriage (in-laws, step-parents, step-children)
  10. Public Guardian and Trustee (PGT) of BC or a person appointed by PGT

To qualify as a Substitute Decision Maker, the person must be:

    • 19 years of age or older,
    • capable,
    • have no dispute with you, and
    • in contact with you in the past year.

Your health-care provider will contact the Public Guardian and Trustee if:

  • no one from the list can be reached or qualifies, or
  • there is dispute between two equally ranked people on the list and the health-care provider cannot resolve the conflict.

See here for more information on the role of the Public Guardian and Trustee

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