Healthy living

Advance care planning process

  • Advance care planning involves talking about your values, beliefs and preferences for health and personal care with your loved ones and those involved in your care.
  • There are a number of advance care planning documents available in WA for you to record your values, care preferences and treatment decisions.
  • Updates to the advance care planning information resources and documents in WA were made in August 2022.

You may want to have a say in the type of care you receive throughout your life. This can become difficult at times when you are unwell and may be unable to make or communicate your wishes.

This process of preparing for this is called advance care planning. Advance care planning can start at any age. It is best started when you are feeling well and able to make decisions. Advance care planning is an ongoing process and involves 4 key elements: Think, Talk, Write, Share.

You can move between these elements and change your choices to suit changes in your personal situation, health or lifestyle.

The advance care planning process: Think, Talk, Write and Share

The information below outlines the advance care planning process, some information on the documents and tools you will need, and where to learn more. For more guidance on how to get started and explore each of the elements refer to Your Guide to Advance Care Planning in WA: A workbook for planning your future care (PDF 1.5MB).

Think

What matters most to me now? What will matter most to me when I become less well?

Your advance care planning process will be guided by you and your beliefs, values and preferences.

Spend time gathering your thoughts and thinking about what ‘living well’ means to you. Do you have any worries about your future? Does your health affect your day-to-day life? If you become unwell, who would you like around you and where would you prefer to receive care? Are there any medical treatments that you would not want?

These resources may help you to consider these questions and think about what matters to you:

Why is advance care planning important?

Advance care planning can give you peace of mind by knowing that others understand your wishes in case a time comes when you are no longer able to tell them what is important to you.

It can also make it easier for your family, friends and health professionals who may care for you in the future.

Families and friends of those who take part in advance care planning say they feel less stressed and are happier with the care their loved one received.

Talk

Talking about advance care planning is a way of letting your loved ones and those involved in your care know what you do and do not want to happen with your future health and care. A close or loving relationship does not always mean someone knows what is important to you. Having a conversation can be very important.

Who can you talk to about advance care planning?

You might want to discuss your needs and what is important for you with people you trust. This may include:

  • family
  • friends
  • carer(s)
  • enduring guardian(s) (if appointed)
  • GP or another member of your healthcare team
  • legal professional
  • cultural or spiritual person.

The Where to get help section has a list of services who you can talk to about advance care planning.

What are some things to talk about?

Talk to your loved ones about your values and beliefs, and the care you would like when you are unwell.

Discuss your health concerns and options for future care with your health professionals. 

The Advance Care Planning Australia conversation starters (external site) can help you when talking to others.

It can be uncomfortable to talk about what might happen if you become unwell in future. It may help to think about the right time to have the conversation and find a place that feels comfortable. Family and friends often have their own opinions about what you should consider in advance care planning. While it may be helpful to hear what others think, remember that you should decide what is best for you.

Take your time – remember that advance care planning is an ongoing conversation and you do not need to talk about everything at once.

Write

Once you have thought about what is important to you and talked with others, it is a good idea to write down what you decide.

Thinking about what types of decisions and thoughts (PDF 1486KB) you want to share will help you decide which document(s) could be useful.

In WA there are different documents you can use to make your values and preferences for your future care known.

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.

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.

Share

What should I do with my completed advance care planning documents?

It is important to let the people close to you know where to find your advance care planning documents.

Store the original in a safe place. Upload a copy to My Health Record (external site) so health professionals can access the information. You can also share copies with:

  • family, friends and carers
  • enduring guardian(s) (EPG)
  • enduring power(s) of attorney (EPA)
  • health professionals and specialists (e.g. GP)
  • residential aged care facility
  • local hospital
  • legal professional

Make a list of the people who have a copy of your advance care planning document(s). This will be a good reminder of who to contact if you change or revoke (cancel) your document(s) in future. See Frequently Asked Questions for more information on revoking and updating advance care planning documents.

If you decide to make an Advance Health Directive, you can also carry:

Resources

Advance care planning general information

Advance care planning documents

Advance Health Directive

Other documents

Advance care planning resources in alternate formats and language options are available on the advance care planning page.

Where to get help

Advance care planning

  • Department of Health WA Advance Care Planning Information Line
    General enquiries and to order advance care planning resources  (e.g. Advance Health Directives, Values and Preferences form)
    Phone: 9222 2300
    Email: ACP@health.wa.gov.au
  • Palliative Care Helpline
    Information and support on issues to do with advance care planning, palliative care, grief and loss
    Phone: 1800 573 299 (9:00 am to 5:00 pm every day)
    Palliative Care WA (external site)
  • Advance Care Planning Australia Free Support Service
    General queries and support with completing advance care planning documents
    Phone: 1300 208 582 (Monday to Friday 9:00 am – 5:00 pm AEST)
    Online referral form (external site)

Enduring Powers of Guardianship and Enduring Powers of Attorney

Last reviewed: 01-08-2022
Palliative Care WA helpline: 1800 573 299. White text on purple background. with two women talking on a bench in bottom right corner