Advance care planning process

Statutory documents

Some of these are statutory documents which are recognised under legislation in WA. and, in most situations, must be followed. The strongest and most formal way of recording your wishes for future health and personal care is a statutory document. Statutory documents must:

• be made by an adult with capacity
• be made by the person (not by someone else on their behalf)
• be signed by the person and witnessed according to formal requirements.

Examples include:

Advance Health Directive 

• A legal record of your decisions about treatment(s) you do or do not want to receive if you become unwell or injured in future.
• An Advance Health Directive is only used if you become unable to make or communicate decisions. If this happens, your Advance Health Directive becomes your ‘voice’. It can only be used if the information in it is relevant to the treatment or care you need.
• You can include medical, surgical and dental treatments, palliative care and measures such as life-support and resuscitation. It is helpful to be as specific as possible in your treatment decisions.
• The form was revised in August 2022 and now includes a ‘Values and preferences’ section where you can write down things that are most important to you about your health and care. The questions in this section are the same as those in the Values and Preferences Form.
• Follow the Guide to Making an Advance Health Directive in WA (PDF 1.5MB) for step-by-step instructions on what can be included and how to have it signed and witnessed correctly.

Enduring Power of Guardianship (external site)

• A legal document that authorises a person to make personal, lifestyle and treatment decisions on your behalf.
• You can choose the person who undertakes this role. This person is known as an enduring guardian or health and lifestyle decision-maker.
• An enduring guardian could be authorised to make decisions about things such as where you live, the support services you have access to and the treatment you receive.
• You can have more than one enduring guardian. However, they must agree on any decisions they make on your behalf.
• An enduring guardian cannot make decisions about property or finances on your behalf.

Non-statutory documents

Other less formal documents can also be used for advance care planning. These are called non-statutory documents. They are not recognised by specific legislations and do not carry the same legal force and may be less likely to be followed than statutory documents.

Examples in WA include:

Values and Preferences Form: Planning for my future care

• A statement of your values, preferences and wishes in relation to your future health and care.
• Your wishes may not necessarily be health related but will guide treating health professionals, enduring guardian(s) and/or family as to how you wish to be treated, including any special preferences, requests or messages.
• The questions are the same as the ‘My values and preferences’ section of the Advance Health Directive. If you are not yet ready to complete a full Advance Health Directive with formal witnessing and signing requirements, you may like to start with completing this form.

Advance care plan for a person with insufficient decision-making capacity (external site) 

• An advance care plan written on your behalf by a recognised decision-maker(s) who has a close and continuing relationship with you (i.e. the person highest on the Hierarchy of treatment decision-makers who is available and willing to make decisions). This type of advance care plan would only be used when making medical treatment decisions on behalf of someone who does not have an Advance Health Directive and who is no longer able to make or communicate their own decisions. It can only be used to guide and inform care and treatment decisions. It cannot be used to give legal consent to, or refusal of treatment.

Clinical documents

Goals of Patient Care

• Goals of Patient Care is a planning process led by a health professional during an admission to hospital or other care facility.
• The process involves a conversation with you and, where relevant, your family or carer(s), to decide which treatments may be useful for you if your condition worsens. Your health professional uses a Goals of Patient Care form to write down the decisions you make together.
• Advance care planning and discussions about goals of care are separate but related processes. If you have an advance care planning document such as an Advance Health Directive or a Values and Preferences Form, you should share a copy with your healthcare team. This can help inform your goals of care discussions.

• The GoPC form has been adapted for use in different settings of care e.g. the Paediatric GoPC and the Residential Goals of Care (RGoC) form. The RGoC form is specifically for residents of aged care facilities to support shared decision-making between the resident, their family / carers and the healthcare team for end of life care preference and priorities. These forms should be done during case meetings where there is enough time for discussion. RGoC forms be reviewed regularly with the resident, their family / carers.

Other documents related to advance care planning

Some people may considered other topics that are not related to health or that cant be recorded in advance care planning documents during the advance care planning process. These may include:

• Organ and tissue donation
  Organ and tissue donation cannot be formally registered using advance care planning documents. Register at DonateLife (external site).
• Wills
  A will is a written, legal document that says what you want to do with your money and belongings when you pass away. Refer to the Public Trustee (external site) for more information.
• Enduring Power of Attorney (EPA)
  An Enduring Power of Attorney is a legal agreement that enables a person to appoint a trusted person - or people - to make financial and property decisions on their behalf. Refer to the Office of the Public Advocate (external site) for more information 

Who will make treatment decisions for me if I cannot make or communicate my own decisions?

Health professionals must follow a certain order when seeking a decision about treatment for you if you are unable to make decisions or tell people what you want.

This is called the Hierarchy of treatment decision-makers.

It is important you understand who may be making decisions for you. This can help you decide who you need to tell about what is important to you and which advance care planning document(s) would be useful.