Advance Care Planning: Making Sure Their Wishes Are Honoured
Only 14% of Australians have a completed advance care directive. Yet 70% say they want to die at home — and only 14% actually do. The gap between wishes and outcomes is often caused by one thing: no written plan.
Advance care planning is the process of thinking about, discussing, and documenting preferences for future healthcare — particularly when a person can no longer speak for themselves. It is one of the most important conversations a family can have, and one of the most avoided. This guide covers what advance care planning is, the documents involved, the state-by-state legal requirements across Australia, how to start the conversation, how to choose a substitute decision maker, and common mistakes that leave families in crisis.
Why This Matters
of Australians have an advance care directive
want to die at home — only 14% do
of hospital deaths involve end-of-life decisions
of families say planning reduced conflict
What Is Advance Care Planning?
Advance care planning is a process, not just a form. It involves:
Thinking
Reflecting on values, beliefs, and preferences about future healthcare. What matters most — comfort, independence, being at home, avoiding certain treatments, religious considerations?
Talking
Discussing these preferences with family, carers, and your GP. The conversation is as important as the document. It helps family members understand the reasoning behind decisions.
Writing
Documenting preferences in a legally recognised advance care directive. This ensures wishes are followed even if the person can no longer communicate. Different states have different forms and legal requirements.
Appointing
Choosing a substitute decision maker (also called a medical treatment decision maker, enduring guardian, or health attorney depending on the state) who will make decisions when the person cannot.
Sharing
Giving copies to the GP, the hospital, the substitute decision maker, and family members. A plan that nobody knows about is useless. Register it where possible (some states have registries).
Reviewing
Updating the plan after major health changes, hospitalisations, or changes in circumstances. An advance care directive from 10 years ago may no longer reflect current wishes.
Types of Advance Care Planning Documents
Australia does not have a single national advance care directive. Each state and territory has its own legislation, terminology, and forms. The key documents are:
Advance Care Directive (ACD)
A legally binding document that records a person's preferences for future medical treatment. It can include specific instructions (e.g., "I do not want CPR") and general values (e.g., "I value comfort over life extension"). Comes into effect only when the person loses decision-making capacity.
Used in: SA, VIC, QLD, WA, NT (terminology varies by state)
Advance Health Directive (AHD)
Similar to an ACD but with state-specific requirements. In Queensland, for example, it must be witnessed by a Justice of the Peace or solicitor and include a doctor's certificate confirming capacity. Some states require specific forms while others accept free-form documents.
Used in: QLD (Advance Health Directive), NSW (not legislated — use common law ACD)
Statement of Wishes / Values Statement
A non-legally-binding document that describes the person's values, preferences, and what matters to them. While not enforceable in the same way as an ACD, it provides crucial guidance to substitute decision makers and clinicians. Often used alongside a formal directive.
Accepted in all states as supplementary guidance
Substitute Decision Maker Appointment
A legal document appointing a person to make medical decisions on the person's behalf when they lose capacity. Different from a financial power of attorney — this covers healthcare decisions only. The appointed person's title varies by state (see table below).
Essential in all states — prevents family disputes at the bedside
State-by-State Guide
Each Australian state and territory has different legislation, document names, witnessing requirements, and registries. This table summarises the key differences.
| State | Directive Document | Decision Maker Title | Witnessing Requirements | Registry |
|---|---|---|---|---|
| VIC | Advance Care Directive | Medical Treatment Decision Maker | 2 witnesses (1 must be authorised — doctor, nurse, JP, lawyer) | No state registry. Give copies to GP and hospital. |
| NSW | Advance Care Directive (common law) | Enduring Guardian | No specific form required. Enduring Guardian needs solicitor or registrar. | No state registry. Enduring Guardian registered with NSW Civil & Administrative Tribunal. |
| QLD | Advance Health Directive | Enduring Power of Attorney (personal/health) | Witness by eligible witness (JP, solicitor, doctor) + capacity certificate | No formal registry. Store with GP, solicitor, and family. |
| SA | Advance Care Directive | Substitute Decision-Maker | 1 witness who is authorised (JP, lawyer, doctor, pharmacist, nurse) | SA ACD Registry (online) — advancecaredirectives.sa.gov.au |
| WA | Advance Health Directive | Enduring Guardian | 2 witnesses (1 must be authorised — JP, lawyer, doctor) | No state registry. Give copies to GP, hospital, and family. |
| TAS | Advance Care Directive | Enduring Guardian | 2 witnesses (neither can be a beneficiary) | No state registry. Guardianship Board registers Enduring Guardian. |
| ACT | Advance Care Direction (Health Direction) | Health Attorney | 2 witnesses. Health Direction must have doctor certification of capacity. | No formal registry. Register Health Attorney with ACT Civil & Administrative Tribunal. |
| NT | Advance Personal Plan | Decision Maker (under APP) | 2 witnesses (1 must be authorised — JP, lawyer, health practitioner) | No state registry. NT Office of the Public Guardian can store copies. |
Important Note on Cross-Border Recognition
If your parent moves interstate or is hospitalised interstate, their advance care directive may not be automatically recognised under the new state's legislation. While most clinicians will respect an out-of-state directive, it is best practice to create a new one in the state of residence. Advance Care Planning Australia (1300 208 582) can advise on specific cross-border situations.
How to Start the Conversation
This is the hardest part. Most families avoid it because it feels morbid, confronting, or disrespectful. But the alternative — making life-and-death decisions in a hospital corridor with no guidance — is far worse.
Choose the Right Moment
Don't bring it up during a crisis or at a family gathering. A quiet, one-on-one visit is ideal. Natural openings include: after a friend or relative's health event, after a hospital visit, during a GP appointment, or when discussing practical matters like wills or insurance.
Start with Values, Not Medical Procedures
Don't lead with "Do you want CPR?" Instead, ask about what matters to them: "What does a good day look like for you?" "What would you not want to live without?" "Where would you want to be if you were very unwell?" These questions naturally lead to treatment preferences.
Use Conversation Starters
Advance Care Planning Australia provides free conversation starter resources. The "What Matters Most" card game makes it feel less like a legal process and more like a meaningful chat. Download at advancecareplanning.org.au/resources.
Don't Try to Do It in One Session
This is a process, not a single conversation. It may take several chats over weeks or months. Let your parent reflect between conversations. Don't push if they're not ready — come back to it. The goal is understanding, not completion.
Include the GP
The GP is the most trusted health professional for most elderly Australians. Ask the GP to raise advance care planning at the next appointment. GPs can discuss specific medical scenarios (e.g., stroke, dementia progression) that help the person make informed decisions. Medicare item numbers exist for GP-led advance care planning consultations.
Involve the Whole Family
While the primary conversation should be one-on-one, the broader family needs to understand the decisions. Siblings who disagree about care create enormous conflict at the bedside. A family meeting — facilitated by a social worker if needed — can prevent disputes before they happen.
Common Mistakes That Leave Families in Crisis
| Mistake | What Happens | How to Avoid It |
|---|---|---|
| No written directive | Family members disagree at the bedside. Clinicians default to "do everything." The person's actual wishes are unknown. | Complete a legally valid advance care directive. Even a simple values statement is better than nothing. |
| Too vague | "I don't want to suffer" doesn't help clinicians make specific decisions. What counts as suffering? | Include specific scenarios: CPR, ventilation, artificial nutrition, dialysis, antibiotics for infection, hospitalisation vs staying at home. |
| Not telling anyone | A directive locked in a safe deposit box is useless in an ambulance at 2am. | Give copies to GP, hospital (ask for medical record), substitute decision maker, and all close family members. |
| Choosing the wrong substitute decision maker | The eldest child is not always the best choice. Someone who lives interstate or struggles with medical discussions may freeze under pressure. | Choose someone who can stay calm, advocate firmly, and follow the person's wishes even if they personally disagree. |
| Never updating it | An ACD from 2010 doesn't reflect a 2026 diagnosis of dementia. Circumstances and wishes change. | Review after any major health event, hospitalisation, new diagnosis, change in living situation, or every 2-3 years. |
| Confusing with financial power of attorney | A financial POA cannot make medical decisions. A medical decision maker cannot access bank accounts. They are separate appointments. | Ensure BOTH financial and medical powers are appointed. They can be the same person but are separate legal documents. |
How Daily Calls Support Advance Care Planning
Early Detection of Cognitive Changes
An advance care directive must be made while the person has decision-making capacity. Daily calls detect early signs of cognitive decline — confusion, repetition, disorientation — giving families a window to complete planning before capacity is lost. Once capacity is gone, it is too late to create a legally valid directive.
Monitoring Health Trajectory
Daily welfare data builds a picture of how a person's health is changing over time. If a parent is declining — eating less, moving less, sleeping more — this may be the right time to revisit their advance care plan and ensure it still reflects their wishes. Families get the data to have informed conversations with the GP.
Peace of Mind for Decision Makers
The hardest part of being a substitute decision maker is the fear of making the wrong choice. When families have consistent, documented evidence of their parent's daily wellbeing, values, and expressed preferences over time, the weight of end-of-life decisions becomes more bearable. Daily calls provide that evidence.
Key Contacts
Advance Care Planning Australia
1300 208 582
National advisory service. Free resources, templates, and guidance on state-specific requirements.
My Aged Care
1800 200 422
Gateway to aged care services. Can connect you with social workers for advance care planning support.
Palliative Care Australia
1800 660 055
National Palliative Care Service — advice on end-of-life care, pain management, and planning.
State Guardianship Tribunals
Varies by state
VIC: VCAT (1300 018 228). NSW: NCAT. QLD: QCAT. SA: SACAT. WA: SAT.
Legal Aid (All States)
Varies by state
Free or low-cost legal help with advance care directive preparation. Available in every state.
GP / Family Doctor
Your parent's GP
Ask about Medicare-funded advance care planning consultation (MBS item 132186). GP can facilitate the conversation.
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