Advance care planning FAQs

What is advance care planning?

A voluntary process of planning for future health and personal care whereby the person’s values, beliefs and preferences are made known to guide decision-making at a future time when that person cannot make or communicate their decisions.

What is the difference between advance care planning, a Values and Preferences Form, an Advance Care Plan and an Advance Health Directive?

As a part of advance care planning, individuals may choose to complete an advance care planning document to record their values, beliefs, preferences and treatment decisions. In WA, advance care planning documents include the following:

• A Values and Preferences Form: Planning for my future care (PDF 485KB), is a document in which an individual can record what they value and what they want for their care in the future including where they want to live, and other things that are important to them. This form may be considered a Common Law Directive.
• An Advance Care Plan for someone with insufficient decision-making capacity (external site) is a document written on an individual’s behalf by a recognised decision-maker(s) who has a close and continuing relationship with the individual (i.e. the person highest on the hierarchy of treatment decision-makers who is available and willing to make decisions). This document can be used to guide decision-makers and health professionals when making medical treatment decisions on the individual’s behalf, if they do not have a valid Advance Health Directive or Values and Preferences Form. It should only be used when a person no longer has decision-making capacity to complete a Values and Preferences Form or an Advance Health Directive. This document is a non-statutory document and is not a document in which a person is able to give legal consent to or refuse treatment. Non-statutory documents are not recognised under specific legislation.
• An Advance Health Directive (PDF 578KB) is a legal record of an individual’s decisions about treatment(s) they do or do not want to receive if they become unwell or injured in future. It can only be made by a person older than 18 years who is able to make and communicate their own decisions. The Advance Health Directive is a statutory document as it is recognised under legislation. Statutory documents are the strongest and most formal way to record an individual’s wishes.

Who needs to do advance care planning?

Everyone should consider advance care planning, regardless of their age or health. It can be particularly important to individuals such as people with an advanced chronic illness, a life-limiting illness, are aged 75+ years or at risk of losing competence.

When should an advance care planning discussion be reviewed?

• When the person and/or carer/ family requests or changes their mind about any previous decisions.
• Where the person’s medical condition or individual circumstances change (e.g. diagnosis of new illness, death of a carer/partner, change in location of care etc).
• When returning to hospital for any treatment.
• If treatment options or medical care available for the patient changes their needs in regards to advance care planning (for example, a new treatment for their disease, diagnosis of a co-morbidity etc).

What is an Advance Health Directive?

An Advance Health Directive (AHD) is a legal document that enables a person to make decisions now about the treatment they would want - or not want - to receive if they ever became sick or injured and were incapable of communicating their wishes. In such circumstances, their AHD would effectively become their voice.

The term 'treatment' includes medical, surgical and dental treatments, including palliative care and life-sustaining measures.

An AHD would come into effect only if it applied to the treatment a person required and only if the person was unable to make reasoned judgements about a treatment decision at the time that the treatment was required.

Why is it helpful to make an Advance Health Directive?

Completing an Advance Health Directive is helpful as it will allow health professionals to know what treatment a person would want - or not want - to receive if they ever became sick or injured and were incapable of communicating their wishes.

It will also help to reassure the person and their loved ones that they have a clear idea of what is desired by the person in the event of illness or injury. 

What if a person has not made an Advance Health Directive?

An AHD is voluntary, a person does not have to make one. There is a hierarchy of treatment decision makers (PDF 1.6MB) that health professionals are required to follow, which is designed to give the authority to those who are most likely to know the person’s values, beliefs and preferences. At the top of the hierarchy is the Advance Health Directive.

If a person identified as being a decision maker (also known as the person responsible) is not contactable or readily available or declines to make a decision, health professionals need to contact the next person responsible in the hierarchy of decision makers.

When will an Advance Health Directive be used?

An Advance Health Directive will only be used at times when an individual is unable to make and/or communicate decisions about their treatment and health care and if it applies to the treatment that they require. In these circumstances, the AHD acts as the person’s voice as it was made before they lost capacity and it expresses their values, beliefs and preferences.

How long is an Advance Health Directive valid?

Decisions an individual makes in an Advance Health Directive are valid:

• until they die or
• until they revoke (cancel) their Advance Health Directive or
• while the treatment options listed in their Advance Health Directive remain relevant. An existing Advance Health Directive will not apply to new treatment options that may become available after an individual completes the Advance Health Directive.

If a person used an old template for their Advance Health Directive is it still valid?

Yes. If the person made an Advance Health Directive using an old version of the form prior to 4 February 2023 and they followed all legal requirements to complete the form, it will continue to be valid.

If they are making a new Advance Health Directive, it is strongly recommended to use the current Advance Health Directive.

If they use the old form past 4 February 2023 it may be considered a valid Advance Health Directive on a case-by-case basis, provided it meets the legal requirements of the Guardianship and Administration Act 1990.

How often and when should a person review their Advance Health Directive?

It is recommended that individuals review their Advance Health Directive every 2 to 5 years, or if their circumstances change. For example, if they are diagnosed with a new ongoing and/or life limiting illness they may need to review their Advance Health Directive earlier than 2 to 5 years.

Rather than amending an Advance Health Directive, individuals should complete a new Advance Health Directive (PDF 548KB), making sure that it complies with the witness requirements.

The person will need to revoke any previous Advance Health Directives.

What is the difference between a Common Law Directive and an Advance Health Directive?

Common Law Directives are written or verbal communications which convey a person’s wishes regarding future health and personal care to be provided or withheld in specific future circumstances. There are no formal requirements in relation to Common Law Directives. There can be significant difficulties in establishing that a particular Common Law Directive is valid at law and can be followed. For this reason they are not recommended for making treatment decisions.

An Advance Health Directive is a legal record of an individual’s decisions about treatment(s) they do or do not want to receive if they become unwell or injured in future. It can only be made by a person older than 18 years who is able to make and communicate their own decisions. The Advance Health Directive is a statutory document as it is recognised under legislation. Statutory documents are the strongest and most formal way to record an individual’s wishes.

What is a life-sustaining treatment?

Life-sustaining treatment is health care that aims to keep a person alive and/or stay alive if they are at risk of dying. Examples of life-sustaining treatment include:

• CPR (cardiopulmonary resuscitation) (e.g. treatment to keep the heart pumping when it has stopped beating) assisted ventilation (e.g. a machine that helps with breathing through a face mask or a breathing tube)
• artificial hydration (e.g. fluids given via a tube into a vein, tissues or the stomach)
• artificial nutrition (e.g. a feeding tube through the nose or stomach)
• receiving blood products (e.g. a blood transfusion)
• antibiotics (e.g. drugs given to help fight infection, given by mouth injection or by drip tube).

Can an Advance Health Directive include permission for organ and tissue donation?

No. An Advance Health Directive cannot be used to formally register a person’s interest in organ and tissue donation. Organ and tissue donation should be formally registered at donatelife.gov.au. It is also important that individuals talk to family members about decisions about organ and tissue donation, as relatives will be asked to agree to this if they die.

Can a person consent to voluntary assisted dying in their Advance Health Directive?

No. Voluntary assisted dying is a legal option for Western Australians who meet the required eligibility criteria. It is not possible to include voluntary assisted dying in an Advance Health Directive, but if it is something a person might consider as an option, they can speak with their healthcare provider or contact the WA VAD Statewide Care Navigator Service. The care navigators who staff the service are qualified health professionals with a wealth of knowledge regarding voluntary assisted dying as an end-of-life choice. They have extensive experience supporting patients, families and health professionals.

Who needs to witness the person’s signature on an Advance Health Directive?

The person making an Advance Health Directive must sign in the presence of 2 witnesses. If they are physically incapable of signing this Advance Health Directive, they can ask another person to sign for them. They must be present when the person signs for them.

Each of the witnesses must be 18 years of age or older and cannot be the person making the Advance Health Directive or the person signing for them (if applicable).

At least one of the witnesses must be authorised by law to take statutory declarations. Schedule 2 of the Oaths, Affidavits and Statutory Declarations Act 2005 (external site) has the full list of people who can witness a statutory declaration. All registered health professionals and lawyers are included on this list.

The witnesses must also sign the Advance Health Directive. Both witnesses must be present when each of them signs. The person making the Advance Health Directive (and the person signing for them, if applicable) must also be present when the witnesses sign.

Can a person be forced to sign an Advance Health Directive against their will?

No. All treatment decisions made in an Advance Health Directive must be made voluntarily. A treatment decision that was forced/made against an individual’s will under inducement or coercion is not valid. If a family member or health professional suspects that an Advance Health Directive was not made voluntarily or was influenced by inducement or coercion, an application should be made to the State Administrative Tribunal under the Guardianship and Administration Act 1990 for a determination of (in)validity.

Can a person ask their doctor to witness their Advance Health Directive?

Yes. A person may ask their doctor to witness their Advance Health Directive. The doctor must sign as a witness, in the presence of another witness (who also needs to be over 18 years of age).

Can a person ask a family member to witness their Advance Health Directive?

Yes. However, it is recommended that independent witnesses are chosen rather than family members.

Can a person ask their translator to witness their Advance Health Directive?

No. If a person used the services of a translator when preparing their Advance Health Directive, their translator cannot witness their signature on the Advance Health Directive.

A person is not able to sign an Advance Health Directive – can someone else sign on their behalf?

If a person is unable to sign their completed Advance Health Directive, they can ask someone else to sign it on their behalf. The person who signs on their behalf will have to complete the second option on the signing page in Part 6 of the Advance Health Directive.

If the person wishes to ‘sign’ the Advance Health Directive themselves by making a mark of any kind, other than a signature, they must complete the marksman clause provided with the Guide to Making an Advance Health Directive in Western Australia (PDF 1.5MB) and attach it to Part 6 of their Advance Health Directive. The same witnessing requirements apply even if the person is using a marksman clause. If a person is including a marksman clause, it is recommended they seek legal advice from a solicitor or community legal service.

Can a person include additional pages to their Advance Health Directive?

Yes. A person can add more information to their Advance Health Directive as long as they do this before it is signed and witnessed. Additional pages cannot be added to an Advance Health Directive once it is witnessed and signed.

How does a person add pages to their Advance Health Directive?

To add pages to an Advance Health Directive:

• use a format that is consistent with the relevant section of the Advance Health Directive to which pages are being added.
  • if adding pages to Part 4.1, use the additional pages for Part 4.1 – Other life-sustaining treatment decisions (PDF 66KB) provided within the Guide to Making and Advance Health Directive in WA
  • if adding pages to Part 4.2, use the additional pages for Part 4.2 – Other treatment decisions (PDF 82KB) provided within the Guide to Making an Advance Health Directive in WA.
  • If adding a translator statement, use the translator statement (PDF 74KB) provided with the Guide to Making an Advance Health Directive in WA, and attach it to Part 5.1
  • if adding a marksman clause, use the marksman clause (PDF 70KB)provided with the Guide to Making an Advance Health Directive in WA and attach it to Part 6
• physically attach (e.g. staple) the additional pages to the relevant section of the Advance Health Directive
• sign and date the bottom of the additional pages when the Advance Health Directive (Part 6) is being signed and witnessed.

Make sure the witnesses sign the bottom of any additional pages attached to the Advance Health Directive at the same time as they sign Part 6.

Can a person make additions and/or changes to the decisions in their Advance Health Directive once it has been signed and witnessed?

No. A person cannot add to and/or change the decisions in their Advance Health Directive after it has been signed and witnessed. If they need to change their Advance Health Directive, they should revoke (or cancel) their current Advance Health Directive and make a new one.

What happens if the person changes their address or contact details after their Advance Health Directive has been signed and witnessed?

An Advance Health Directive remains valid if a person changes their address and/or contact details. A person does not need to revoke (cancel) their Advance Health Directive if only their personal details change. They can simply let the people who have a copy of their Advance Health Directive know their updated personal details.

How does a person revoke (or cancel) their Advance Health Directive?

To revoke an Advance Health Directive, a person must have full legal capacity. The law provides safeguards to ensure that Advance Health Directives cannot be made, amended or revoked if a person does not have capacity. There is a statement in the Advance Health Directive that allows individuals to indicate that they are revoking a previous version. The WA Department of Health recommends that individuals inform the relevant people and organisations (who may have a copy of the Advance Health Directive) that they have revoked (cancelled) their Advance Health Directive. This may include their GP, other health professionals, healthcare providers, family members and/or friends who currently hold a copy of their Advance Health Directive. Everyone who has an old copy of the person’s Advance Health Directive should return it to them, and the person should destroy the old copies.

Is the Advance Health Directive available in a language other than English?

No. The Advance Health Directive is only available in English and responses must be written in English to be valid. This guide and other advance care planning information is available in multiple languages on HealthyWA.

Can a person engage the services of a translator to help in making an Advance Health Directive?

Yes, a person can engage the services of a translator when making an Advance Health Directive. It is recommended that the translator be qualified and/or credentialed in translating.

What should a translator and maker of an Advance Health Directive complete when making an Advance Health Directive?

A person and their translator should complete the translator statement provided with the Guide to Making an Advance Health Directive in WA and attach it to Part 5.1 of their completed Advance Health Directive. 

How does a person make an Advance Health Directive if they are vision impaired, or if they are unable to read and/or write?

Being unable to read and/or write, and/or sign their name does not prevent a person from making an Advance Health Directive. They can ask someone to read the Advance Health Directive (and this guide) to them, and they can ask for help to complete the Advance Health Directive. If they are unable to sign their completed Advance Health Directive, they can ask someone else to sign it on their behalf. The person who signs on behalf of the person will have to complete the second option on the signing page in Part 6.

If a person wishes to ‘sign’ the Advance Health Directive themselves by making a mark of any kind, other than a signature, they must complete the marksman clause provided with this guide and attach it to Part 6 of their Advance Health Directive. The same witnessing requirements apply even if the person uses a marksman clause. If the person includes a marksman clause, it is recommended that they seek legal advice from a solicitor or community legal service.

How does a person make a certified copy of their Advance Health Directive?

A certified copy is a photocopy of a document that has been certified as a direct copy of the original document by an authorised witness. There is no legislation in WA that states either how to certify a copy of a document and/or who can do it. However, it is usual for documents to be certified by a person who is authorised as a witness for statutory declarations under Schedule 2 of the Oaths, Affidavits and Statutory Declarations Act 2005.

For more information on certifying copies of an Advance Health Directive, see the website of the Office of the Public Advocate (external site) or Department of Justice Information Fact Sheet – Certifying Copies of Documents (external site).

What should a person do with their completed Advance Health Directive?

They should keep their original Advance Health Directive in a safe place. They can store a copy of their Advance Health Directive online using My Health Record. To upload an Advance Health Directive to My Health Record visit the Digital health website (external site). It is recommended that a person tells those close to them and those involved in their care that they have made an Advance Health Directive. A person can share a copy of their completed Advance Health Directive with as many people that are close to them as they would like. This may include:

• family, friends and carers
• enduring guardian(s)
• GP/local doctor
• other specialist(s) and/or other
• health professionals
• residential aged care home
• local hospital
• legal professionals.

A person can also use the following, to let people know that they have an Advance Health Directive:

• carry an Advance Health Directive alert card (PDF 327KB) in their purse or wallet – they can order an alert card by contacting the Department of Health Advance Care Planning Line on 9222 2300 or email acp@health.wa.gov.au.
• wear a MedicAlert (external site) bracelet.

People should be advised to write a list of all the people who have a current copy of their advance care planning documents should they wish to revoke or update them in the future.

How will health professionals know that someone has written an Advance Health Directive?

Health professionals cannot honour something that they do not know exists. It is the responsibility of the person to make sure that everyone who may be involved in their care is aware that they have written an Advance Health Directive, or appointed an Enduring Guardian, or both.

Health professionals have a responsibility to identify whether a person has an Advance Health Directive by asking the person or their family/ carer, checking patient records and checking My Health Record.

Does a person have to register their Advance Health Directive?

No. A person is not legally required to register their Advance Health Directive. It is recommended that they tell people close to them and those who are involved in their care that they have made an Advance Health Directive and share a copy with those individuals.

What is an Enduring Power of Guardianship?

An Enduring Power of Guardianship (EPG) is a legal document that authorises a person of the individual’s choice, to make important personal, lifestyle and treatment decisions on the individual’s behalf should they ever become incapable of making or communicating decisions themselves. This person(s) is known as an enduring guardian.

A person can authorise an enduring guardian to make decisions for them about where they live, the support services they have access to, and the treatment(s) they receive. A person cannot authorise an enduring guardian to make decisions about their property or financial matters. A person can have more than one enduring guardian but they must act jointly which means they must reach agreement on any decisions they make on the person’s behalf. For more information on Enduring Power of Guardianship and enduring guardians, visit the Office of the Public Advocate (external site).

Who can appoint an enduring guardian?

A person must be 18 or over and have the capacity to form their own decision on making an EPG.

When will an enduring guardian have the power to make decisions for the person?

The EPG will only be used if and when an individual becomes unable to make decisions for themselves.

The person can choose the decisions the enduring guardian will be able to make, such as where they live and what treatment and services they receive.

If the person makes an Advanced Health Directive this will take priority over the decisions of the enduring guardian for the treatment stated in the document, as per the hierarchy of treatment decision-makers (PDF 1.6MB).

What is the difference between Enduring Power of Guardianship and an Advanced Health Directive?

An Enduring Power of Guardianship (EPG) is a legal document which an individual can appoint one or more persons as an enduring guardian to make personal, lifestyle and treatment decisions for them.

The person can choose the type of decisions their enduring guardian will be able to make. These decisions include where they will live, and what treatment they will receive.

An Advance Health Directive (AHD) is a legal document completed by an adult with full legal capacity which contains decisions regarding future treatment. It specifies the treatment(s) for which consent is provided or refused under specific circumstances and only comes into effect if the person becomes incapable of communicating their wishes.

A person can have both an AHD and EPG, but having an AHD overrides the EPG when it comes to treatment.

This means that if they are unable to make a treatment decision themselves, the instructions in their AHD will be used instead of asking the enduring guardian to make these decisions on their behalf, unless the AHD is invalid or does not cover the required treatment.

If a person makes an Advance Health Directive, do they need to make an Enduring Power of Guardianship too?

No. A person is under no obligation to make an Enduring Power of Guardianship just because they have made an Advance Health Directive. However, by appointing an enduring guardian, they will increase the likelihood that decisions made on their behalf will reflect their values, beliefs and preferences if they become unable to make or communicate these decisions themselves.

What is the difference between an enduring guardian and an enduring attorney?

An enduring attorney is not able to make personal, lifestyle and treatment decisions on the persons behalf. The authority of the enduring attorney is limited to making decisions about financial affairs and property.

It is possible for the same person to be appointed as both the guardian and enduring attorney at the same time.  This often happens when one family member has more ability or time to undertake the role.

Can an enduring guardian be appointed in an Advance Health Directive?

A person cannot use their Advance Health Directive to appoint an enduring guardian. To appoint an enduring guardian they must complete an Enduring Power of Guardianship form which is available from the Office of the Public Advocate (external site)..

Can a guardian or enduring guardian make an Advance Health Directive for them?

It is not possible for another person to make an Advance Health Directive on their behalf.  This has to be done by the person while they have capacity.

Additional FAQs on Enduring Power of Guardianship can be found on the Office of the Public Advocate Enduring Power of Guardianship frequently asked questions (external site).

Do health professionals always need to follow decisions recorded in an Advance Health Directive?

Yes. In most situations, if a person becomes unable to make or communicate decisions about their treatment and care, health professionals must follow the decisions in their Advance Health Directive, except in some limited exceptions. A limited exception may occur if:

• circumstances relevant to a treatment decision have changed since the person made the treatment decision, and
• the person could not have reasonably anticipated those changes when they made their Advance Health Directive, and
• it is likely that a reasonable person with knowledge of the change of circumstances would change their mind about the treatment decision.

I have concerns regarding the person’s (Enduring) Guardian – what should I do?

A person’s enduring guardian must act in the best interest of the person.

If health professionals have concerns about an enduring guardian, it is important to talk to others involved in the person’s care. It could be helpful to arrange a meeting with the person’s enduring guardian and the treating medical team including social work, to try and resolve it. If apprehensions remain, an application can be made to the State Administrative Tribunal (SAT) (external site) detailing the concerns.

I have concerns regarding the circumstances in which an Advance Health Directive was created – what should I do?

If health professionals have concerns, firstly they could discuss these with the person if possible. Health professionals may also check if the person has listed the details of person(s) they have contacted for medical or legal advice and discuss concerns with them. If the person lacks capacity, then it is important to discuss concerns with the person’s usual medical team or identified decision maker as per the hierarchy of treatment decision-makers (PDF 1.6MB). If concerns remain, an application can be made to the State Administrative Tribunal (SAT) (external site) to determine the document’s validity.

The person’s Advance Health Directive consents to treatment I do not consider to be appropriate – what should I do?

People can sometimes write down treatment decisions which health professionals may disagree with, but these decisions may still be valid.

The Advance Health Directive may not be used to demand treatment which is not clinically required. The first step is to discuss with the person (and where possible, their usual treatment team) the best option for the person’s treatment at that time.

If the person lacks capacity, this discussion should be made with the relevant substitute decision maker as per the hierarchy of treatment decision-makers (PDF 1.6MB).

The person’s Advance Health Directive does not cover their current situation – What should I do?

If the person has capacity

Health professionals should obtain consent from them prior to initiating any treatment.

If the person’s current situation is likely to recur and the treatment in their current Advance Health Directive will have a significant impact, then providing the person has capacity, they may consider making a new Advance Health Directive and revoking the previous one.

If the person has lost capacity

And the treatment decisions contained in their Advance Health Directive do not meet their current non-urgent medical requirements, health professionals must refer to the hierarchy of treatment decision-makers (PDF 1.6MB) and contact the correct person for consent.

If an urgent decision is required, the health professional’s treatment decisions must be based on the person’s best interests.

The person’s Advance Health Directive and their enduring guardian/family are seeking different treatments – what should I do?

Once a person has lost capacity, the hierarchy of treatment decision-makers (PDF 1.6MB) must be consulted to clarify who to approach for consent.  The Advance Health Directive must be followed first and if valid, will overrule the wishes of the enduring guardian in these circumstances.

If the family remain concerned, they can apply to the State Administrative Tribunal (SAT) (external site) to determine the validity of the Advance Health Directive.

The person, within the hospital in which I work, has given me their Advance Health Directive – What should I do?

Make sure that the person retains their original Advance Health Directive and they are giving the health professionals a copy (preferably a certified copy).

If they have given the health professional their original Advance Health Directive, health professionals can make a copy and return the original Advance Health Directive back to them.

The Advance Health Directive should be prominently placed within the patient’s file and where possible uploaded into the electronic medical record. It is important that health professionals follow their relevant organisational guidance and practice in relation to managing this document. For health professionals within WA Health, refer to relevant statewide policies for the storage of advance care planning documents:

• WA Clinical Alert (MedAlert) Policy.

What if nobody can access the Advance Health Directive in an emergency situation?

Treatment is regarded as urgent or an emergency if it is needed to save a person's life or prevent the person from suffering significant pain or distress.

Where a person requires urgent treatment and it is not practicable for the health professional to determine whether an Advance Health Directive has been made or to obtain a treatment decision from anybody in the hierarchy of treatment decision-makers (PDF 1.6MB), the health professional may provide the necessary treatment.

In cases where a person is in need of urgent treatment that the health professional believes is the result of attempted suicide, the health professional may administer the necessary treatment even:

• if the person has made an Advance Health Directive in which consent for the required treatment is withheld
• the person's guardian, enduring guardian or person with authority to make a decision withholds consent.