Health professionals can support people to document values, beliefs and preferences by:
- discussing the options of documents – noting which are statutory and which are not (see the advance care planning documentation flowchart for WA)
- providing advice and guidance about treatment decisions to consider and the potential outcome(s) of their choices
- encouraging the person to write down their decisions about medical treatment in their own words
- refer people to relevant organisations for assistance (see Where to get advice)
- encouraging a review of advance care planning document(s) every 2 years or when there are changes to a person’s condition or health.
When helping people decide which advance care planning documentation is right for them, it is useful to refer to the Hierarchy of treatment decision-makers (PDF 1.5MB). This explains the order in which health professionals must consult decision-makers when seeking a treatment decision for a person who lacks capacity.
Statutory documents
A statutory advance care planning document is the most formal way to record a person’s values, preferences and treatment decisions. Such documents are recognised under WA legislation and must:
- be made by an adult with capacity (adults are considered to have capacity unless proven otherwise)
- be made by the individual, not by someone else on their behalf
- meet formal witnessing and signing requirements.
Because of these requirements, statutory documents have the strongest legal force and generally must be followed. There are unique statutory documents for WA including:
Advance Health Directive (AHD)
An Advance Health Directive is a legal document completed by a competent adult and contains decisions regarding future medical treatment. It specifies the treatment(s) for which consent is provided, refused or withdrawn under specific circumstances and only comes into effect if it applies to treatment a person requires, and only if the person becomes incapable of making or communicating their decisions.
An Advance Health Directive includes a values and preferences section which includes the same questions as those in the Values and Preferences Form. By completing an Advance Health Directive, all the information can be included in one statutory document.
Health professionals should be familiar with the Guide to Making an Advance Health Directive in WA (PDF 15.MB) for instructions on how to complete an Adavance Health Directive.
Enduring Power of Guardianship (EPG)
An Enduring Power of Guardianship (external site) is a legal document in which a person nominates an enduring guardian to make personal, lifestyle and treatment decisions on their behalf in the event that they are unable to make reasonable judgements about these matters in the future. An EPG is different from an Enduring Power of Attorney (EPA), which relates to financial and property matters.
Non-statutory documents
Non-statutory documents are not recognised by WA legislation and do not carry the same legal force as a statutory document. Documents include:
Values and Preferences Form: Planning for my future care
A Values and Preferences Form (PDF 487KB) is a statement of a person’s values, preferences and wishes in relation to their future health and care. Wishes may not necessarily be health-related but will guide treating health professionals, enduring guardian(s), family members and carers in how a person wishes to be treated, including any special preferences, requests or messages. In some cases, this may be considered a valid Common Law Directive – although this is not the recommended format to make treatment decisions.
The questions in this form are the same as the ‘Values and preferences’ section of the Advance Health Directive. If people are not yet ready to complete a full Advance Health Directive with formal witnessing and signing requirements, they may like to start with a Values and Preferences Form.
Advance care plan for a person with insufficient decision-making capacity
An Advance care plan for a person with insufficient decision-making capacity (external site) is an advance care plan that can be completed by a person’s recognised decision-maker(s) (i.e. person highest on the Hierarchy of treatment decision-makers who is available and willing to make decisions) who has a close and continuing relationship with the person. This plan can be used to guide decision-makers and health professionals when making medical treatment decisions on behalf of the person, if the person does not have an Advance Health Directive or Values and Preferences Form. It should only be used when a person no longer has sufficient decision-making capacity to complete an Advance Health Directive or Values and Preference Form. This form cannot be used to give legal consent to, or refusal of treatment.
Clinical documents
Goals of Patient Care
Goals of Patient Care (GoPC) establishes the most medically appropriate, realistic, agreed goal of patient care that will apply in the event of clinical deterioration, during an episode of care. GoPC and advance care planning are separate but related processes. A GoPC form is available for use in WA. This document prompts and facilitates proactive shared decision-making between treating health professionals, the person and their families.
GoPC forms should align with the person's advance care planning documents and may include treatment decisions that were not considered when the person prepared their advance care planning documents. The content of any advance care planning document should be discussed during a GoPC discussion. The health professional should ask the person if they agree to upload a copy of their GoPC to My Health Record.
The GoPC form has been adapted for use in different settings of care e.g. the Paediatric GoPC and the Residential Goals of Care form.
Common Law Directives
In some cases, non-statutory documents may be recognised as a Common Law Directive. 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. All documents, including non-statutory documents, are important in terms of having conversations with loved ones that may become decision-makers on behalf of that individual in the future.
Other documents related to advance care planning
Other topics that are not related to health or that cant be recorded in advance care planning documents may arise during discussions. Be aware of where to refer people for assistance if these topics are raised.
- Organ and tissue donation
Encourage people to register via DonateLife (external site) as organ and tissue donation cannot be formally registered using advance care planning documents.
- Wills
A will is a written, legal document that says what a person wants to do with their money and belongings when they die. Refer to the Public Trustee (external site).
- 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).
Seeking clarity on the validity of documents
If you have concerns about the validity of an Advance Health Directive or Enduring Power of Guardianship, and the person has capacity, you should discuss your concerns with the person.
If the person does not have capacity, you should: