[r. 7]
[Heading inserted: SL 2022/102 r. 5.]
ADVANCE HEALTH DIRECTIVE FORM | ||||||||||
This form is for people who want to make an Advance Health Directive in
Western Australia. To make an Advance Health Directive, you must be 18 years or older and
have full legal capacity. Your Advance Health Directive is about your future
treatment. It will only come into effect if you are unable to make reasonable
judgments or decisions at a time when you require treatment. Part 4, marked with this symbol, contains your treatment decisions. If
you choose not to make any treatment decisions in Part 4, then the
document is not considered a valid Advance Health Directive under the
Guardianship and Administration Act 1990 . Please tick the box below to indicate that by making this Advance Health
Directive you revoke all prior Advance Health Directives completed by you. ∗ In making this Advance Health Directive, I
revoke all prior Advance Health Directives made by me. This form includes instructions to help you complete your Advance Health
Directive. For more information on how to complete the form and to see
examples, please read A Guide to Making an Advance Health Directive in Western
Australia . Before you make your Advance Health Directive, you are encouraged to seek
legal and/or medical advice, and to discuss your decisions with family and
close friends. It is important that people close to you know that you have
made an Advance Health Directive and where to find it. Once you complete your
Advance Health Directive, it is recommended that you: •
store the original in a safe and accessible place and tell your close
family and friends that you have made an Advance Health Directive and where to
find it •
upload a copy of your Advance Health Directive to your My Health
Record — this will ensure that your Advance Health Directive is
available to your treating doctors if it is needed •
give a copy of your Advance Health Directive to health professionals
regularly involved in your health care (for example, your General Practitioner
(GP), a hospital you attend regularly, and/or other health professionals
involved in your care). This form must be completed in English. If English is not your first language,
you may need help to understand and complete this form. Contact the National
Accreditation Authority for Translators and Interpreters for help. | ||||||||||
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PART 1: MY PERSONAL DETAILS You must complete this part | ||||||||||
You must complete Part 1. You must include the date, your full name, date of birth and address. |
This Advance Health Directive is made under the Guardianship and
Administration Act 1990 Part 9B on the ........... of
..................., ........... by ...................................................................... (name) | |||||||||
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Full name | | |||||||||
Date of birth | | |||||||||
Address | | |||||||||
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WA |
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Phone number | | |||||||||
Email | | |||||||||
PART 2: MY HEALTH | ||||||||||
2.1 My major health conditions | ||||||||||
Use Part 2.1 to list details about your major health conditions (physical
and/or mental). Cross out Part 2.1 if you do not want to complete it. |
Please list any major health conditions below: | |||||||||
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2.2 When talking with me about my health, these
things are important to me | ||||||||||
Use Part 2.2 to provide information about what is important to you when
talking about your treatment. This might include: How much you like to know about your health
conditions What you need to help you make decisions about
treatment Whether you like to have certain family members
with you when receiving information from your health professionals Cross out Part 2.2 if you do not want to complete it. |
Please describe what is important to you when talking to health professionals
about your treatment: | |||||||||
PART 3: MY VALUES AND PREFERENCES | ||||||||||
This part encourages you to think about your values and preferences relating
to your health and care now and into the future. This may help you to decide
what treatment decisions you want to make in Part 4: My Advance Health
Directive Treatment Decisions. In this part, you are not making decisions about your future treatment. Use
Part 4 to make decisions about your future treatment. Cross out any parts that you do not want to complete. | ||||||||||
3.1 These things are important to me | ||||||||||
Use Part 3.1 to provide information about what “living well”
means to you now and into the future. This might include: What the most important things in your life are What “living well” means to you Cross out Part 3.1 if you do not want to complete it. |
Please describe what “living well” means to you now and into the
future. Use the space below and/or tick which boxes are important for you. | |||||||||
Please describe: | ||||||||||
∗ Spending time with family and friends ∗ Living independently ∗ Being able to visit my home town, country
of origin, or spending time on country ∗ Being able to care for myself (e.g.
showering, going to the toilet, feeding myself) ∗ Keeping active (e.g. playing sport,
walking, swimming, gardening) ∗ Enjoying recreational activities, hobbies
and interests (e.g. music, travel, volunteering) ∗ Practising religious, cultural, spiritual
and/or community activities (e.g. prayer, attending religious services) ∗ Living according to my cultural and
religious values (e.g. eating halal, kosher foods only) ∗ Working in a paid or unpaid job | ||||||||||
| ||||||||||
3.2 These are things that worry me when I think
about my future health | ||||||||||
Use Part 3.2 to provide information about things that worry you about
your future health. This might include: Being in constant pain Not being able to make your own decisions Not being able to care for yourself Cross out Part 3.2 if you do not want to complete it. |
Please describe any worries you have about the outcomes of future illness or
injury: | |||||||||
| ||||||||||
3.3 When I am nearing death, this is where I would
like to be | ||||||||||
Use Part 3.3 to indicate where you would like to be when you are nearing
death. When you are nearing death, do you have a preference of where you would like
to spend your last days or weeks? Cross out Part 3.3 if you do not want to complete it. |
Please indicate where you would like to be when you are nearing death. Tick
the option that applies to you. You can provide more detail about the option
you choose in the space below. | |||||||||
∗ I want to be at home — where I
am living at the time ∗ I do not want to be at home —
provide more details below ∗ I do not have a preference — I
would like to be wherever I can receive the best care for my needs at the time
∗ Other — please specify: | ||||||||||
Please provide more detail about your choice: | ||||||||||
| ||||||||||
3.4 When I am nearing death, these things are
important to me | ||||||||||
Use Part 3.4 to provide information about what is important to you when
you are nearing death. This might include: What would comfort you when you are dying Who you would like around you Cross out Part 3.4 if you do not want to complete it. |
Please describe what is important to you and what would comfort you when you
are nearing death. Use the space below and/or tick which boxes are important
for you. | |||||||||
Please describe: | ||||||||||
∗ I do not want to be in pain, I want my
symptoms managed, and I want to be as comfortable as possible | ||||||||||
∗ I want to have my loved ones and/or pets
around me | ||||||||||
∗ It is important to me that cultural or
religious traditions are followed | ||||||||||
∗ I want to have access to
pastoral/spiritual care | ||||||||||
∗ My surroundings are important to me (e.g.
quiet, music, photographs) | ||||||||||
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PART 4: MY ADVANCE HEALTH DIRECTIVE TREATMENT DECISIONS | ||||||||||
This part of your Advance Health Directive contains treatment decisions in
respect of your future treatment. A treatment is any medical or surgical
treatment (including palliative care or life‑sustaining measures such as
assisted ventilation and cardiopulmonary resuscitation), dental treatment, or
other health care. A treatment decision in an Advance Health Directive is a decision to consent
or refuse consent to the commencement or continuation of any treatment and
includes a decision to consent or refuse consent to the commencement or
continuation of the person’s participation in medical research. This
decision applies at any time you are unable to make reasonable judgments in
respect of that treatment. Treatment you consent to in this Advance Health Directive can be provided to
you. Treatment you refuse consent to in this Advance Health Directive cannot
be provided to you. Your enduring guardian or guardian or another person
cannot consent or refuse consent on your behalf to any treatment to which this
Advance Health Directive applies. It is recommended that you discuss your treatment decisions with your doctor
before completing this part. Cross out any parts that you do not want to complete. You MUST make at least one treatment decision in Part 4 to make a valid
Advance Health Directive. | ||||||||||
4.1 Life‑sustaining treatment decisions | ||||||||||
Use Part 4.1 to indicate your instructions for future
life‑sustaining treatments. You can give an overall instruction or list individual treatments that you
consent or refuse consent to receiving in the future. You can also list
circumstances in which you consent or refuse consent to a particular
treatment. Life‑sustaining treatments are treatments used to keep you alive or to
delay your death. Read all options before making a decision. The options are over two pages. Cross out Part 4.1 if you do not want to complete it. You MUST make at least one treatment decision in Part 4 to make a valid
Advance Health Directive. |
If I do not have the capacity to make or communicate treatment decisions about
my health care in the future, I make the following decisions about
life‑sustaining treatment: (Tick only one of the following options. If you choose Option 4, complete the
table overleaf). | |||||||||
Option 1 |
∗ I consent to all treatments aimed at
sustaining or prolonging my life. | |||||||||
OR | ||||||||||
Option 2 |
∗ I consent to all treatments aimed at
sustaining or prolonging my life unless it is apparent that I am so unwell
from injury or illness that there is no reasonable prospect that I will
recover to the extent that I can survive without continuous
life‑sustaining treatments. In such a situation, I withdraw consent to
life‑sustaining treatments. | |||||||||
OR | ||||||||||
Option 3 |
∗ I refuse consent to all treatments aimed
at sustaining or prolonging my life. | |||||||||
OR | ||||||||||
Option 4 |
∗ I make the following decisions about
specific life‑sustaining treatments as listed in the table below. | |||||||||
OR | ||||||||||
Option 5 |
∗ I cannot decide at this time | |||||||||
Please complete this table if you have ticked Option 4 above. If you have ticked Option 1, 2, 3 or 5, do not complete this table. | ||||||||||
This table lists some common life‑sustaining treatments. Use the boxes
to indicate which treatments you consent or refuse consent to receiving. You
can also list circumstances in which you consent to treatment. There is also
space for you to add any life‑sustaining treatments not listed here. Tick one box per row in the table below. If you choose Option B for any treatments, please specify the circumstances in
which you consent to the treatment. | ||||||||||
Life‑sustaining treatment |
A. I consent to this treatment in all circumstances |
B. I consent to this treatment in the following circumstances |
C. I refuse consent to this treatment in all circumstances |
D. I cannot decide at this time | ||||||
CPR Cardiopulmonary resuscitation |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
Assisted ventilation A machine that helps you breathe using a face mask or tube |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
Artificial hydration Fluids given via a tube into a vein, tissues or the stomach |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
Artificial nutrition A feeding tube through the nose or stomach |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
Receiving blood products such as a blood transfusion |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
Antibiotics Drugs that are used to treat infection |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
Use the boxes below to list any other life‑sustaining treatments you
do/do not consent to receive: | ||||||||||
Other life‑sustaining treatment (1) State the treatment: . ........................ |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
Other life‑sustaining treatment (2) State the treatment: ......................... |
∗ |
∗ |
∗ |
∗ | ||||||
In which circumstances do you consent to this treatment? | ||||||||||
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4.2 Other treatment decisions | ||||||||||
Use Part 4.2 to indicate your decisions for other
(non‑life‑sustaining) treatments. There are a range of other treatments that may be options for you in the
future. Examples include treatments for mental health (e.g. electroconvulsive therapy)
and drugs used to prevent certain health conditions (e.g. aspirin, cholesterol
treatments). When making a treatment decision, list the circumstances in which you want
your decision to apply (e.g. in all circumstances, or specify particular
circumstances). A treatment decision only applies in the circumstances you specify. Please ensure that you indicate in the “My treatment decisions”
column whether you consent or refuse consent to any treatment you refer to. If you need more space, use the template in the Guide to Making an Advance
Health Directive in Western Australia and attach it to your Advance Health
Directive form. Cross out Part 4.2 if you do not want to complete it. You MUST make at least one treatment decision in Part 4 to make a valid
Advance Health Directive. |
Health circumstances |
My treatment decisions | ||||||||
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∗ I have made more treatment decisions using
the template and attached ......... (specify number of pages) additional
pages. |
4.3 Medical research | |||||
Use Part 4.3 to provide treatment decisions about the medical research
activities you consent or refuse consent to take part in, and any
circumstances in which these decisions apply. Taking part in medical research may be an option for you even if you are
unable to make or communicate decisions. A treatment decision may include deciding whether to start or continue to take
part in medical research. Your involvement in medical research, and any
treatments you receive as part of the medical research, must be consistent
with what you have agreed in your Advance Health Directive. The decisions you
make in your Advance Health Directive about participating in medical research
only operate while you are alive. If you do not make a decision about participation in medical research,
Part 9E of the Guardianship and Administration Act 1990 will operate
as to how decisions will be made about participation in medical research. Cross out Part 4.3 if you do not want to complete it. You MUST make at least one treatment decision in Part 4 to make a valid
Advance Health Directive. | |||||
Please tick a box showing whether you consent to taking part in the listed
medical research activities and the circumstances in which you consent. You
may tick more than one circumstance for each research activity. | |||||
RESEARCH ACTIVITIES |
I consent to taking part in the following circumstances: |
I do not consent | |||
Where I require urgent treatment to save my life, or to prevent serious damage
to my health, or to prevent me suffering or continuing to suffer significant
pain and distress |
Where the medical research may improve my condition or illness |
Where the medical research may not improve my condition or illness but may
lead to a better understanding of my condition or illness in the future |
Where there are no other treatment options | ||
The administration of pharmaceuticals or placebos (inactive drug) |
∗ |
∗ |
∗ |
∗ |
∗ |
The use of equipment or a device |
∗ |
∗ |
∗ |
∗ |
∗ |
Providing health care that has not yet gained the support of a substantial
number of practitioners in that field of health care |
∗ |
∗ |
∗ |
∗ |
∗ |
Providing health care to carry out a comparative assessment |
∗ |
∗ |
∗ |
∗ |
∗ |
Taking blood samples |
∗ |
∗ |
∗ |
∗ |
∗ |
Taking samples of tissue or fluid from the body, including the mouth, throat,
nasal cavity, eyes or ears |
∗ |
∗ |
∗ |
∗ |
∗ |
Any non‑intrusive examination of the mouth, throat, nasal cavity, eyes
or ears |
∗ |
∗ |
∗ |
∗ |
∗ |
A non‑intrusive examination of height, weight or vision |
∗ |
∗ |
∗ |
∗ |
∗ |
Observing an individual |
∗ |
∗ |
∗ |
∗ |
∗ |
Undertaking a survey, interview or focus group |
∗ |
∗ |
∗ |
∗ |
∗ |
Collecting, using or disclosing information, including personal information |
∗ |
∗ |
∗ |
∗ |
∗ |
Considering or evaluating samples or information taken under an activity
listed above |
∗ |
∗ |
∗ |
∗ |
∗ |
Any other medical research not listed above |
∗ |
∗ |
∗ |
∗ |
∗ |
PART 5: PEOPLE WHO HELPED ME COMPLETE THIS FORM | |||||
5.1 Did an interpreter help you to complete this
form? | |||||
Use Part 5.1 to show whether an interpreter helped you to complete this
form. If English is not your first language, you can use an interpreter to help you
complete this form. If you use an interpreter to help you to complete this Advance Health
Directive, you and your interpreter should complete the interpreter statement
provided in A Guide to Making an Advance Health Directive in Western Australia
and attach it to your Advance Health Directive. Cross out Part 5.1 if you do not want to complete it. |
Tick the option that applies to you: | ||||
Option 1 |
∗ English is my first language —
I did not need to use an interpreter | ||||
Option 2 |
∗ English is NOT my first
language — an interpreter helped me make this Advance Health
Directive and I have attached an interpreter statement | ||||
Option 3 |
∗ English is NOT my first
language — | ||||
| |||||
5.2 Have you made an Enduring Power of
Guardianship (EPG)? | |||||
Use Part 5.2 to indicate whether you have made an Enduring Power of
Guardianship (EPG) and provide details if relevant. An Enduring Power of Guardianship allows you to name and legally appoint one
or more people to make decisions about your lifestyle and health care if you
lose capacity. A person you appoint to make decisions on your behalf is called an enduring
guardian. An enduring guardian cannot override decisions made in your Advance Health
Directive. Cross out Part 5.2 if you do not want to complete it. |
Tick the option that applies to you: | ||||
Option 1 |
∗ I have NOT made an Enduring Power of
Guardianship | ||||
Option 2 |
∗ I have made an Enduring Power of
Guardianship | ||||
My EPG was made on: ....... / ........... / ........ (day) (month) (year) My EPG is kept in the following place (be as specific as possible):
...............................................................
............................................................................ |
|||||
I appointed the following person/s as my enduring guardian. Name ....................................... Phone
.................... Joint enduring guardian (if appointed): Name ....................................... Phone
..................... | |||||
Substitute enduring guardian (if any): Name ....................................... Phone
..................... Other substitute enduring guardian (if more than one): Name ....................................... Phone
..................... | |||||
| |||||
5.3 Did you seek medical and/or legal advice about
making this Advance Health Directive? | |||||
Use Part 5.3 to indicate whether you obtained medical and/or legal advice
before making this Advance Health Directive and provide details if relevant. You are encouraged (but not required) to seek medical or legal advice to make
an Advance Health Directive. Cross out Part 5.3 if you do not want to complete it. |
Medical Advice — tick the option that applies to you | ||||
Option 1 |
∗ I did NOT obtain medical advice about the
making of this Advance Health Directive. | ||||
Option 2 |
∗ I DID obtain medical advice about the
making of this Advance Health Directive. I obtained medical advice from: | ||||
|
Name | | |||
Phone | | ||||
Practice | | ||||
Legal Advice — tick the option that applies to you | |||||
Option 1 |
∗ I did NOT obtain legal advice about the
making of this Advance Health Directive. | ||||
Option 2 |
∗ I DID obtain legal advice about the making
of this Advance Health Directive. I obtained legal advice from: | ||||
|
Name | | |||
Phone | | ||||
Practice | | ||||
| |||||
PART 6: SIGNATURE AND WITNESSING You must complete this Part | |||||
•
You must sign this Advance Health Directive in the presence of
two (2) witnesses. If you are physically incapable of signing this
Advance Health Directive, you can ask another person to sign for you. You must
be present when the person signs for you. •
Two (2) witnesses must be present when you sign this Advance Health
Directive or when another person signs for you. •
Each of the witnesses must be 18 years of age or older and cannot
be you or the person signing for you (if applicable). •
At least one of the witnesses must be authorised by law to take
statutory declarations. •
The witnesses must also sign this Advance Health Directive. Both
witnesses must be present when each of them signs. You and the person signing
for you (if applicable) must also be present when the witnesses sign. •
If you need to use a marksman clause to sign this Advance Health
Directive, you should complete the marksman clause template provided in A
Guide to Making an Advance Health Directive in Western Australia and attach it
to your Advance Health Directive. | |||||
YOU MUST SIGN THIS FORM IN THE PRESENCE OF TWO (2) WITNESSES. BOTH WITNESSES
MUST BE PRESENT WHEN YOU SIGN THIS FORM. THE WITNESSES MUST SIGN IN EACH
OTHER’S PRESENCE. Signed by:
..........................................................................................
(signature of person making this Advance Health
Directive) Date: ......... /............ /........... (day) (month) (year) OR Signed by:
..........................................................................................
in the presence of, and at the direction of
..........................................................................................
Date: ........ /............ /.......... Witnessed by a person authorised by law to take statutory declarations: | |||||
Authorised witness’s signature | | ||||
Authorised witness’s full name | | ||||
Address | | ||||
Occupation of authorised witness | | ||||
Date |
......... / ............ / ............ | ||||
And witnessed by another person: | |||||
Witness’s signature | | ||||
Witness’s full name | | ||||
Address | | ||||
Date |
......... / ............ / ............ |
[Schedule 2 inserted: SL 2022/102
r. 5.]
This is a compilation of the Guardianship and Administration
Regulations 2005 and includes amendments made by other written laws. For
provisions that have come into operation, and for information about any
reprints, see the compilation table.
Citation |
Published |
Commencement | ||
---|---|---|---|---|
21 Jan 2005 p. 268‑9 |
24 Jan 2005 (see r. 2 and Gazette 31 Dec 2004
p. 7130) | |||
Guardianship and Administration Amendment Regulations 2009 |
15 Sep 2009 p. 3583‑97 |
r. 1 and 2: 15 Sep 2009 (see r. 2(a)); | ||
Guardianship and Administration Amendment Regulations (No. 2) 2009 |
18 Dec 2009 p. 5168‑9 |
r. 1 and 2: 18 Dec 2009 (see r. 2(a)); | ||
Reprint 1: The Guardianship and Administration Regulations 2005 as at 5 Mar
2010 (includes amendments listed above) | ||||
Guardianship and Administration Amendment Regulations 2022 |
SL 2022/102 17 Jun 2022 |
r. 1 and 2: 17 Jun 2022 (see r. 2(a)); |
Defined terms
[This is a list of terms defined and the provisions where they
are defined. The list is not part of the law.]
Defined term Provision(s)
commencement day
9(1)
former regulations 9(1)
transitional period 9(1)