Advance Directive for Dementia, CHSLD, and Seniors in Quebec

A dementia diagnosis doesn't just change medical care — it starts a legal clock. The DMA, protection mandate, and DAAMM require the person to be capable at the moment of signing. A diagnosis alone does not determine capacity, so the planning window depends on the person's actual ability to understand and decide.

Why Timing Is Everything After a Diagnosis

Quebec law draws a hard line on capacity. The DMA, the protection mandate, and the DAAMM all require the signer to understand what they're agreeing to at the time they sign. There is no partial credit. Capacity is assessed in context: a person with mild cognitive impairment may still have legal capacity, while a moderate-to-advanced condition may affect the ability to make these decisions.

This creates an urgent planning window — the period between diagnosis and the loss of legal capacity. For Alzheimer's disease, that window can be years. For rapidly progressive dementias like frontotemporal dementia or Creutzfeldt-Jakob disease, it can be months or weeks.

Families who wait until the person "gets worse" often wait too long. The documents signed during the capable period become the permanent legal framework for every decision that follows.

The Three Documents That Matter

The DMA (Advance Medical Directive) covers five specific treatments: cardiopulmonary resuscitation, mechanical ventilation, dialysis, artificial nutrition, and artificial hydration. For each treatment, the person states accept or refuse under three clinical scenarios: terminal illness in an end-of-life state, irreversible coma or vegetative state, and severe irreversible cognitive decline (including advanced Alzheimer's).

The DMA is binding on medical staff once registered with RAMQ for the five treatments and clinical situations covered by the form. A physician cannot override the directive simply because a family member disagrees. This is the document that determines whether those five interventions happen in the covered clinical situations when the person can no longer communicate.

The protection mandate names a mandataire to handle both personal care and financial decisions. For someone with a dementia diagnosis, this is critical because the mandate is the mechanism designed to give someone legal authority over frozen bank accounts, housing decisions, and healthcare choices beyond the five DMA-covered treatments.

The mandate must be signed while capacity still exists. If capacity is uncertain, a contemporaneous written assessment may help document the person's ability to understand the document at signing; it does not replace the required legal formalities.

The DAAMM (advance request for Medical Assistance in Dying) is available only to people who already have a diagnosis of a serious, incurable disease that will inevitably lead to cognitive incapacity. The request is formulated with a physician or specialized nurse practitioner, specifying the exact clinical symptoms that may trigger consideration of MAID — for example, failing to recognize immediate family members, or loss of the ability to eat independently.

Since October 30, 2024, this mechanism gives people with qualifying diagnoses the option to record the conditions under which MAID may be considered after they've lost the capacity to consent in real time. It does not guarantee administration: all statutory conditions must be met, and practitioner or institutional refusal remains possible.

CHSLD and Nursing Home Admission

When someone is admitted to a CHSLD (Centre d'hébergement et de soins de longue durée), the care team initiates a "Goals of Care" (objectifs de soins or niveaux de soins) discussion. This is a clinical conversation — not a legal document — that determines the level of medical intervention the person will receive.

Levels range from A (full aggressive intervention including ICU and resuscitation) through D (comfort care only, no life-prolonging measures). The outcome is documented in the patient's medical chart.

If the person already has a registered DMA, the goals of care discussion should align with it. But the two systems can conflict — a DMA might refuse resuscitation while a family member pushes for Level A intervention. In these cases, the registered DMA takes legal precedence for the five treatments it covers. The care team is bound by it, and the family cannot override it.

If there is no DMA and no legal representative such as a homologated protection mandatary or tutor, the care team follows the statutory consent hierarchy: the person's spouse, then a close relative or a person with a special interest. This default ordering doesn't always match who the person would have chosen — and it creates openings for family conflict.

Retirement Homes vs. CHSLDs

Private retirement homes (résidences pour personnes âgées) operate differently from public CHSLDs. They are not government-funded and typically serve residents who are more autonomous. But the legal framework for advance directives applies identically:

• A registered DMA is binding on medical professionals for the covered treatments and clinical situations, regardless of the setting
• A homologated protection mandate gives the mandataire authority over care decisions and finances
• The DAAMM process is available to qualifying residents in any setting

The difference is practical: retirement homes may have less clinical infrastructure than CHSLDs, which means transfer to a hospital is more likely for acute situations. Having advance directives in place — and ensuring the retirement home has copies in the resident's file — prevents confusion during emergency transfers.

What to Do Right Now

If the diagnosis is recent and capacity is intact:

Complete the DMA through the RAMQ ClicSÉQUR portal. Sign the protection mandate (notarial or private form). If the diagnosis qualifies for DAAMM, discuss the advance request with the attending physician. Complete the applicable steps while the legal window is open.

If capacity is uncertain:

If capacity is uncertain, seek a contemporaneous capacity assessment before signing. Written evidence of capacity at the time of signing may help address a later challenge, but it does not replace the required legal formalities.

If capacity is already gone:

The window for voluntary documents has closed. The family must now pursue homologation of an existing protection mandate, or if none exists, apply for tutorship through the court — a more complex and expensive process than homologation, with the Curateur public typically involved.

The Quebec Advance Directive Kit includes worksheets for the four planning instruments, with specific guidance for families navigating a dementia diagnosis — including a DMA treatment worksheet, a DAAMM request worksheet for discussing clinical triggers with a physician, and a complete action plan for the post-diagnosis planning window.

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