Advance care planning FAQs

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.

Advance care planning is the voluntary process of planning for future health and personal care whereby your values, beliefs and preferences are made known, to guide decision-making at a future time when you cannot make or communicate your decisions.

As a part of this process, you may choose to complete an advance care planning document to record your values, beliefs, preferences and treatment decisions. Visit the Advance care planning documents and resources page to learn about the different advance care planning documents available in WA which include:

• Values and Preferences Form: Planning for my future care (PDF 486KB)
• Advance Health Directive (PDF 500KB) 
• Enduring Power of Guardianship (external site)

Values and preferences statement for a person with impaired decision-making capacity (external site)  -  completed by another person on your behalf if you are unable to make your own decisions and do not already have an Advance Health Directive or a values and Preference Form.

Everyone should consider advance care planning, regardless of their age or health. It can be particularly important for people who are:

• living with an advanced chronic illness or a life-limiting illness
• aged 75+ years
• at risk of losing competence.

• When the person 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).
• When going to hospital for any treatment.
• If treatment options or medical care available for the patient changes their needs (e.g. a new treatment or cure for their disease becomes available, diagnosis of a co-morbidity).

It is not essential to speak to a medical professional when completing an AHD but it is strongly recommended.

Although the idea that a person should be able to prepare an AHD without medical and/or legal advice is ideal, the more complex and specific a person wishes to make their AHD, the greater value there is in seeking professional assistance in preparing the AHD. Discussing this with a medical professional provides people with an opportunity to clarify and check their understanding of the implications of the decisions they have recorded or intend to record.

In particular, if a person is considering refusing all life-sustaining treatment in AHD, it is recommended they speak with their GP/ specialist so they understand the implications of the decision, particularly if they don’t currently have a diagnosis of a life-limiting illness.

People making a new Advance Health Directive should use the current form (PDF 500KB) prescribed under the Guardianship and Administration Act 1990.  A modified version or different template may not be considered a valid Advance Health Directive in accordance with the legal requirements of the Guardianship and Administration Act 1990.

Individuals should be advised to use the updated form as it was developed through a rigorous consultation process to reflect the findings of the Ministerial Expert Panel on Advance Health Directives and the needs of the community. By using the current form, it is less likely that the validity of the AHD would be queried or challenged. Furthermore, the Department of Health is delivering education to health professionals that is based on the updated form so this is the format that health professionals will be most familiar with.

If individuals are in doubt about the validity of their Advance Health Directive they are encouraged to seek legal advice when completing it. If there are further concerns, the Act allows for an application to be made to the State Administrative Tribunal for a hearing to determine if the document is a valid advance health directive or not.

Please note that the Department of Health only provides general advice regarding Advance Health Directives, not legal advice.  The making, operation and validity of Advance Health Directives is governed by the Guardianship and Administration Act 1990, please see Part 9B for the relevant sections.  The sections in 9B have not changed, only the prescribed form in the Regulations was amended in 2022. The Guardianship and Administrative Act legislation falls within the Attorney-General’s portfolio and is administered by the Department of Justice.

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).

A person can add additional pages to their Advance Health Directive before it is signed and witnessed. Use the additional page templates provided.

An Advance Health Directive cannot be added to and/or changed 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.

To revoke an Advance Health Directive, a person must have full legal 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. 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.

In this situation staff must sensitively and appropriately enquire about the reasons for refusal through a telephone interpreter, LOTE staff member, or an adult friend or family member. The staff member needs to emphasise that health professionals need to understand the information being conveyed to them by the patient and/or carer to deliver appropriate care. If the patient still declines, the staff member must document the following in the consumer’s medical record and/or other relevant records. Refer to Section 3.2 in the WA Health Language Services Procedure (PDF 498KB) for more detailed advice.

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.

It is also recommended to upload a copy to My Health Record (external site) and health professionals can assist patients to do so.

Tip – You may need to scan the Advance Health Directive in black and white and at 300dpi to reduce the PDF file size. Documents larger than 20MB cannot be uploaded to My Health Record.

To reduce the file size of a scanned Advance Health Directive, check scanner settings for the following:

• scan in black and white
• choose the recommended dpi setting for text-based documents e.g. 300 dpi.

These settings will provide the legibility needed and produce a reasonably sized document.

Documents larger than 20MB cannot be uploaded to My Health Record. The Australian Digital Health Agency provides more information for health professionals on uploading advance care planning documents to My Health Record (external site) as well as other practical information on managing advance care planning documents for consumers (external site). The maximum file size varies between other electronic patient record systems. Health professionals should be aware of file size limits and take actions accordingly to ensure patient records can be uploaded.

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.

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.

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.

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).

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.

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.

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. 

• 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.