206 Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse Facilitating Self-Determination and Autonomy with Advance Care Planning In industrialized society, many people value self-​ determi­ nation and autonomy. Self-determination is the power or ability to make decisions for oneself without influence from outside. In hospice and palliative care, it is auton- omy—the right of all competent people to choose to ac- cept or refuse any or all medical therapy, even if refusal means they will die (Meisel, 1989)—that can significantly affect the dying person’s and family’s experience. Specific- ally, promoting autonomy with advance care planning as early as the time of diagnosis can benefit the dying person and their family by: • Avoiding decision making when the person becomes more confused as disease progresses • Providing space for difficult discussions before crises occur • Preventing misunderstandings or misconceptions of the person’s wishes by proxy decision makers • Providing the opportunity for a longer survival time (Zalonis and Slota, 2014) Advance care planning (ACP) is a process in which the person identifies, records, and discusses their wishes for future health care and interventions that are based on their beliefs, values, hopes, fears, and priorities. Having conversations with their family and the physician/nurse practitioner and documenting their (the dying person’s) preferences and wishes will inform the health care team if or when the person is no longer able to direct their own care. Both Canada and the United States have frame- works for advance care planning, available in digital and print formats on websites. ACP helps people to determine their own care through to death and following. Tools for Advance Care Planning In Canada: Speak Up Campaign advancecareplanning.ca In the United States: Five Wishes agingwithdignity.org/five-wishes Appointing a Substitute Decision Maker In many states, provinces, and territories, a person may be able to legally appoint a substitute decision maker (SDM) (Canada) or durable power of attorney for health care (DPOA-HC) (United States) while mentally competent to do so. (To avoid repetition, the abbreviation SDM will represent both these roles in this text.) The SDM will make decisions and speak on the person’s behalf if they become unable to speak for themselves. The theory is that the health care team consults the SDM when necessary, and together they can honor the wishes of the person through dying, death, and post-death care. An SDM is responsible for health care decisions for the person only if the person is no longer able to make their own decisions. An SDM is not able to, for example, contribute to financial decisions. The requirements to appoint an SDM vary in each juris- diction. Providing the person and family with the specifics for your location will be helpful as they begin this process. Selecting an appropriate SDM may be easier if the person considers people who: • Know them well—their personality, likes, and dislikes • Are actively involved in their care • Are aware of current physical and psychosocial issues affecting them or that may affect them • Are comfortable having ACP conversations with the person • Understand that their role as SDM is to honor the per- son’s wishes and make a decision they feel the person would make if they were able to speak for themselves in this particular situation • Understand that they are not to make decisions based on what they themselves would want In other words, an SDM should be someone who can re- spond to the question, If your loved one was here today, given the current health concern and the available options, what do you think he or she would have wanted done? In some families the SDM is assigned according to cultural tradition; for example, the eldest son is assigned to make decisions. In other families, the family may decide as a