Advance Care Planning

INFORMATION SHEET & RESOURCES

For Patients, Carers and Health Professionals
The following information has been compiled to assist you in understanding
the issue of future care planning. Patients, carers, families, health
professionals, hospitals and aged care homes all benefit from clear guidelines
to follow in the event of future health issues.

Advance Care Planning is the process of helping you to make decisions

about your future health care. It involves talking to your family, health care
providers and any other significant people to work out what is important to
you. It is usual to write down your choices. This document is called an
Advance Care Directive.

An Advance Care Directive is a written statement regarding your wishes for

your own future health care. An Advance Care Directive can be made now by
anyone who has the capacity to do so and is only used if at some point in the
future you become incapable of making health care decisions for yourself
(through illness or accident). You may have received an Advance Care
Directive with this fact sheet or you can obtain one from your GP. Advance
Care Directives should be reviewed regularly to ensure that wishes have not
changed.

When a person does not have the capacity to make their own medical
decisions, it will be necessary for the ‘person responsible’ (see over) to make
these decisions on their behalf based on what they believe is in the patient’s
best interest and reflecting what the patient would have wanted. If you wish to
know more ask your GP for the information sheet called Medical Care
Decision Making for Guardians and Families.

What is Capacity?

It is important to be clear about someone’s ability to make their own decisions

whether these be financial, personal or health related. A person who is able to
understand the question at hand, weigh up and understand the consequences
of their own choices is said to have capacity. This person has the right to
make their own financial, health and lifestyle decisions. All adults are
assumed to have capacity. Capacity is only questioned if there is a valid
reason to do so (such as advancing dementia, delirium, psychosis etc). In
these cases a capacity assessment is carried out by the health or legal
professional involved.

Based on document from Central Coast Division of General Practice who developed original
in conjunction with Northern Sydney Central Coast Health.
Rev3:01022030
Who is the Person Responsible?

There is a clear hierarchy set out by the Guardianship Act stating which
people have the right to make decisions on someone’s behalf if that person
can no longer decide. It is no longer necessarily the person’s next of kin.
In order, the person responsible is:
• The court appointed or enduring guardian if one has been appointed
• The most recent spouse or defacto who has an ongoing relationship
with the person
• The person’s primary unpaid carer
• A relative or friend who has a close personal relationship with the
person.

In cases of conflict or absence of an appropriate person the Guardianship

Tribunal can advise. Freecall: 1800 463 928.
Having a conversation with your ‘person responsible’ about what is important
to you and writing an Advance Care Directive will make their job easier.

Enduring Guardian vs Power of Attorney

An Enduring Guardian is someone you choose to make personal, health or

lifestyle decisions on your behalf if and when you lose the capacity to make
decisions yourself.

A Power of Attorney is a legal document authorising someone else to carry

out business, financial or property affairs on your behalf. A standard Power of
Attorney ceases to have effect once you lose capacity. An Enduring Power
of Attorney remains valid if you lose the capacity to carry out these
transactions independently.

Enduring Guardian and Power of Attorney may only be appointed by someone

who has capacity. Telephone 1800 463 928 for free forms or download from
www.planningwhatiwant.com.au Completed forms need to be witnessed by a
lawyer or by appointment with the Clerk of your local courthouse.

Based on document from Central Coast Division of General Practice who developed original
in conjunction with Northern Sydney Central Coast Health.
Rev3:01022030
More information on Advance Care Planning:

• Guidelines for end-of-life care and decision-making, published by

NSW Health, for a copy phone 02 9816 0452 or it is downloadable on
www.health.nsw.gov.au

• Using Advance Care Directives, for health professionals, published

by NSW Health, for a copy phone 02 9816 0452 or downloadable on
www.health.nsw.gov.au

Advance Care Directives available for use in New South Wales:

New South Wales has no mandated form for Advance Care Planning. There
are several forms available for use and it is important that you feel
comfortable with the one that you are completing. Some Advance Care
Directives suitable for NSW are (in alphabetical order):

• Advance Care Directive developed by Dr Jerome Mellor of Moon St

Clinic, Ballina – for more information and free download see
www.moonstmedical.com.au, under ACD heading

• Advance Health Care Directive developed by Professor Colleen

Cartwright, Director, Aged Services Learning and Research
Collaboration, Southern Cross University, available for free download
from http://aslarc.scu.edu.au

• My Advance Care Directive: A declaration of my health care

values, goals and preferences, available for free download from the
Royal Australian College of General Practitioners website,
www.racgp.org.au and search for Advance Care Plans.

• My Health, My Future, My Choice: An Advanced Care Directive for

NSW. The book can be ordered by downloading an order form from
www.advancecaredirectives.org.au or requesting an order form by
phoning 0423 157 003 and sending a cheque or money order payable
to: Advance Care Directive Association Inc. at 18/113 Johnston St,
Annandale NSW 2038 for $12 plus $2 postage

• Palliative Care Advance Care Plan is suitable for people receiving

palliative care. When an illness cannot be cured, the focus of care
changes to helping patients to have the best quality of life possible
while managing their symptoms. This Advance Care Plan was adapted
from a document modified by Warrnambool Palliative Care Service
from Respecting Patient Choices, Austin Health, Melbourne. This
document is available for free download on the Northern Rivers
General Practice Network website www.nrgpn.org.au under Advance
Care Planning heading.

• Respecting Patient Choices provides information about all aspects of

advance care planning. For more information, contact Respecting
Patient Choices (NSW) Program Manager (0410 408 730) or go to
www.respectingpatientchoices.org.au

Based on document from Central Coast Division of General Practice who developed original
in conjunction with Northern Sydney Central Coast Health.
Rev3:01022030