Making an
advance care
directive
NSW Health
3 Making an Advance Care Directive
NSW Ministry of Health
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ST LEONARDS NSW 2065
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TTY. (02) 9391 9900
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SHPN (HSP) 230864
ISBN978-1-76023-659-5
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NSW Health website www.health.nsw.gov.au
November 2023
An Advance Care Directive is an important way
of letting people know your preferences about
your healthcare and treatment in case you are
seriously ill or injured and not able to make
decisions. Having an Advance Care Directive
will make it easier for those signicant to you
and health staff if they need to make decisions
for you. Making an Advance Care Directive is an
important part of Advance Care Planning. For
more information about Advance Care Planning,
please see
health.nsw.gov.au/patients/acp/Pages/
default.aspx and nsw.gov.au/life-events/ planning-
for-end-of-life.
What is an Advance Care Directive?
An Advance Care Directive is a way to say what
healthcare treatments you would like to have or
refuse if you have a life-threatening illness or
injury. Health professionals will use your Advance
Care Directive to make decisions when you are
unable to make or communicate decisions about
the care and treatment you want.
An Advance Care Directive can only be made by
you as an adult with decision making capacity. If it
is valid, it must be followed. Health professionals
and family members have no authority to override
a valid Advance Care Directive.
Why is an Advance Care Directive
important?
None of us know what will happen in the future or
can predict what might happen with our health.
Medical advances mean that there are treatments
which can keep you alive when you are seriously
ill or injured, and which may prolong your life.
Some people have rm ideas about how they
want to live the rest of their life, including
conditions or treatments that they might nd
unacceptable.
In a crisis your family may nd it difcult to
decide what treatment is best for you. An
Advance Care Directive will help your family and
doctors to know what you would want when you
are not able to tell them yourself. It’s best to
write your Advance Care Directive so that your
preferences are clearly recorded.
Making an Advance Care Directive
The purpose of this Information Booklet is to provide information to help
you complete an Advance Care Directive. An example Advance Care
Directive form is provided at the end of the booklet, for you to complete
and tear off.
Making an Advance Care Directive 1
This booklet will help
guide you through
decisions that you may
wish to consider when
making an Advance
Care Directive.
2 Making an Advance Care Directive
How do I prepare for making an
Advance Care Directive?
The rst step is to think about what would be
important to you at end of life and what matters
to you – your values. This may include:
• thinking about what kind of care you would like
to receive or refuse
• who you would like to make decisions on your
behalf and
• where you would like to be cared for if you were
dying.
In the Advance Care Directive form at the back
of this booklet, Section 2 includes space for
you to write some statements if you wish. There
is no right or wrong answer – it is up to you to
identify what is important to let others know.
This information will help your family and those
making decisions for you to understand what
treatment and care you want. Some examples
of statements about values are provided in the
Common Terms section on pages 9–10.
If you’re not sure what you would want, or would
like to read more, the following websites might be
helpful:
• Palliative Care Australia
palliativecare.org.au
• MyValues
myvalues.org.au
The next step is to talk with your family, friends
and health professionals.
Talking to your family and friends can be difcult.
You might start by saying that like writing a Will,
you are planning ahead for a time when you might
not be able to make decisions about your health.
Make it clear to those signicant to you what
treatments you would accept or refuse if you are
very unwell.
Your doctors can help by explaining what
treatments you could include in your Advance
Care Directive based on your current health. They
can also make sure that what you write can be
understood by a health professional.
Working through the Advance Care Directive form
at the back of this booklet will help identify what
is important to you and what you would like to let
those signicant to you and healthcare providers
know about.
2 Making an Advance Care Directive
How do I make a valid
Advance Care Directive?
An Advance Care Directive is valid if:
• you had capacity when you wrote it
• it has clear and specic details about
treatments that you would accept or refuse
• it reects your preferences, rather than the
preferences of another person
• it applies to the situation you are in at the time.
Any document that meets the criteria above is a
valid Advance Care Directive. In NSW, an Advance
Care Directive can be spoken or written. An
example Advance Care Directive form is attached
to this booklet.
Adding your signature and the signatures of
a witness or healthcare professional can help
health professionals to know that an Advance
Care Directive is valid. However, signatures and
witnesses are not required for an Advance Care
Directive to be valid and enforceable.
You must have decision making capacity to make
an Advance Care Directive. If you no longer have
capacity, you cannot make an Advance Care
Directive. However, you or those signicant to
you can still plan for your end of life care and
treatment.
An Advance Care Directive must reect your
preferences; someone else cannot make an
Advance Care Directive on your behalf. However,
someone may assist you to write or document
your preferences.
Who will make healthcare decisions
for you when you no longer can?
The Guardianship Act NSW (1987) outlines who
can make healthcare decisions for you when you
no longer can. This person is called the Person
Responsible.
To nd the Person Responsible, health
professionals will look for someone using the
following list, in order of priority:
1. Your Enduring Guardian or a guardian
appointed by the NSW Guardianship Tribunal
2. Your spouse or defacto partner, who you have
an ongoing relationship with
3. Your carer - someone who provides ongoing
regular care and is not paid for it (excluding
Carers Allowance or similar payments)
4. A close friend or relative who you have an
ongoing relationship with.
If you wish to choose the person who makes
healthcare decisions on your behalf, you
can appoint an Enduring Guardian. For more
information see https://www.service.nsw.gov.au/
transaction/appoint-an-enduring-guardian.
Your Person Responsible must refer to your
Advance Care Directive before making any
medical or health decisions.
When will my Advance Care Directive
be used?
Doctors and health care professionals will only
look at your Advance Care Directive if you are
unable to make or communicate decisions about
your healthcare and treatment.
Making an Advance Care Directive 3
4 Making an Advance Care Directive
Before acting on any instructions that your
Advance Care Directive may contain about your
treatment or care, doctors will assess if it is valid.
Part of that assessment is understanding whether
it applies to your current situation.
For example, if you were admitted to hospital
because you had fallen over and hit your head
and had concussion, and were not able to
communicate your preferences, you would be
expected to get better and parts of your Advance
Care Directive that relate to end of life care may
not be considered to apply to that situation.
However, if you had suffered a major stroke
or heart attack and were unconscious and not
able to communicate, and were not expected
to get better, the doctors may consider that
your Advance Care Directive may apply in that
situation.
Pain relief and managing discomfort are always
important. If your Advance Care Directive states
you want to die a natural death, you will still be
given pain relief if needed.
The NSW Supreme Court has said that valid
Advance Care Directives must be followed. This
is because they are a part of a person’s right
to make decisions about their health. Health
professionals and Persons Responsible have
no authority to override a valid Advance Care
Directive.
Where should I keep my Advance
Care Directive?
You should keep your Advance Care Directive in a
place that is easy for you or someone else to nd
it. It is a good idea to keep a copy with you, or to
keep a card in your wallet that lets people know
that you have an Advance Care Directive and
where it can be found.
It is a good idea to leave copies with your Person
Responsible, family or carer, doctor or healthcare
facility.
You can also upload your Advance Care
Directive directly to My Health Record. For more
information, see
https://www.digitalhealth.gov.au/
initiatives-and-programs/my-health-record/whats-
inside/advance-care-planning
.
Please do not post your Advance Care Directive to
NSW Health. Your local hospital or health service
may discuss ways to store your Advance Care
Directive with you, if this is relevant to you.
Make sure you know where all copies are. If you
change your Advance Care Directive, you will
need to replace all copies.
4 Making an Advance Care Directive
Can I record my preferences
regarding future healthcare in my
Will?
No. A Will only starts to operate after death. Any
information about your health in your Will will
not be available to your Person Responsible or
doctor(s) while you are alive.
Can someone appointed as my Power
of Attorney consent to medical and
dental treatment on my behalf?
No. Their role is to manage your business,
property and nancial matters.
Can I access voluntary assisted dying
by requesting it in my Advance Care
Directive?
No. To access voluntary assisted dying, you must
retain decision-making capacity and the ability to
communicate requests and decisions throughout
the entire process. Because an Advance Care
Directive only comes into effect when you no
longer have capacity, you cannot access voluntary
assisted dying by requesting it in an Advance
Care Directive.
I prepared an Advance Care Directive
when I lived interstate. Is this
recognised now that I live in NSW?
Yes. Advance Care Directives made in other
Australian states and territories are recognised in
NSW.
I have an Advance Care Directive but
have decided that I would like my
Enduring Guardian to make the best
decision they can at the time. Can I
revoke my Advance Care Directive?
Yes, you can retract/cancel/void your Advance
Care Directive at any time while you have
capacity. It is important to make sure you let
people know you have revoked your Advance Care
Directive and destroy all copies.
What if I change my mind about my
Advance Care Directive?
You can change your Advance Care Directive as
often as you like, as long as you have capacity.
It is a good idea to read over anything you have
written once a year, to make sure it is still current.
If you change your Advance Care Directive,
you should make sure you let people know and
replace all of the copies with the new Advance
Care Directive.
What’s the difference between
an Advance Care Directive and an
Advance Care Plan?
An Advance Care Directive can only be made by
you as an adult with decision-making capacity. If
it is valid, it must be followed. No one can override
your Advance Care Directive, not even your legally
appointed guardian.
Frequently Asked Questions
Making an Advance Care Directive 5
6 Making an Advance Care Directive
An Advance Care Plan can be written by you
or on your behalf. It documents your values
and preferences for healthcare and preferred
health outcomes. The plan is prepared from
your perspective and used as a guide for future
healthcare decision making, if you are unable
to speak or otherwise communicate your
preferences for yourself.
An Advance Care Plan may be developed for and/
or with a person with limited capacity (ability to
make decisions), so therefore it does not need to
be followed.
What is capacity?
Capacity refers to an adult’s ability to make a
decision for him or herself.
Capacity is specic to the particular decision that
needs to be made. In some circumstances, the law
sets out what tests must be met for capacity to
make certain decisions, for example to consent to
medical treatment.
Generally, when a person has capacity to make
a particular decision they can do all of the
following:
• understand and believe the facts involved in
making the decision
• understand the main choices
• weigh up the consequences of the choices
• understand how the consequences affect them
• make their decision freely and voluntarily
• communicate their decision.
Can I insist on being given a particular
treatment or procedure?
No. Your health care team will consider your
preferences, but does not have to offer you
treatment that may not benet you.
What about organ and tissue donation
for transplantation?
Organ donation is a life-saving and life
transforming medical process. Organ and tissue
donation involves removing organs and tissues
from someone who has died (a donor) and
transplanting them into someone who, in many
cases, is very ill or dying (a recipient).
People 16 years of age or older can register their
donation decision with the Australian Organ
Donor Register. Details on how to register your
decision can be found at
servicesaustralia.gov.
au/australianorgan-donor-register
or by visiting a
government service centre. Decisions can also be
changed at any time.
It is important that you let your family know
your decisions about organ and tissue donation.
In Australia your family will always be asked to
conrm your donation decisions before organ and
tissue donation can proceed.
Some patients are so severely injured or ill
that they do not respond to lifesaving medical
treatments. The doctors caring for that patient
may agree that they will not survive and that
further medical treatment is no longer of any
benet to them.
The doctors may then ask their family about that
person’s preferences about organ and tissue
donation.
If the person had indicated that they wanted to
become an organ and tissue donor after their
death, the doctors may also ask the family
about several treatments which may be given
before that person dies, only for the purpose of
improving the function of any donated organs
when transplanted. These treatments are of no
medical benet to the patient and are called
antemortem interventions. Examples include
antibiotics, blood thinning drugs or drugs to
control blood pressure.
If you want to be an organ donor, the Advance
Care Directive template attached to this booklet
asks you to declare your consent to antemortem
interventions.
If you do not consent to antemortem interventions,
it is still possible to be an organ donor.
6 Making an Advance Care Directive
Making an Advance Care Directive 7
I’ve heard about body donation –
what is that?
Body donation is where a person’s body is given
to a body donor program and / or a licensed
anatomical facility either following the person’s
written consent prior to their death or with the
consent of their senior available next of kin
after their death. Bodies maybe used for the
teaching of medical and health students, training
of surgeons in new surgical techniques or for
research.
In NSW a body donation program is usually
organised through a university or medical
research facility.
Most body donation programs encourage people
to register to be an organ donor as well as a
body donor, if they would like to do so. Where a
person has consented to body donation and organ
donation, preference is given to organ donation if
suitable, because of its life saving benets.
If you have registered your wish to donate with a
body donor program you should make sure that
your family knows your decision. That way either
your family or hospital staff can contact the
program you are registered with when you die.
Who needs to sign or witness my
Advance Care Directive?
An Advance Care Directives does not need to be
signed or witnessed to be valid.
However, to help health professionals easily know
that your Advance Care Directive is valid, it is
recommended that your Advance Care Directive is
signed by:
• You
• A witness who can verify that your Advance
Care Directive reects your preferences
• A health professional.
Can someone else make an Advance
Care Directive for me?
No. For an Advance Care Directive to be valid, it
must reect your preferences. However, someone
may assist you to write or document your
preferences.
Family members cannot make an Advance
Care Directive for someone who no longer has
decision-making capacity.
8 Making an Advance Care Directive
An Advance Care Directive is an
important way of letting people know
your wishes about your healthcare and
treatment should you nd yourself in a
position where you are seriously ill or
injured and not able to make decisions.
8 Making an Advance Care Directive
Advance Care Planning
Advance Care Planning involves thinking about
what medical care you would like should you nd
yourself in a position where you are seriously
ill or injured and cannot make or communicate
decisions about your care or treatment. It includes
thinking about what is important to you - your
values, beliefs and preferences.
Advance Care Planning can include one or more
of the following:
• talking with your family, carers and/or health
professionals
• developing an Advance Care Plan
• making an Advance Care Directive.
Ideally Advance Care Planning happens early,
when you are well and are able to understand the
choices available to you about your healthcare
and treatment. However it can be done at any
time you have capacity.
An Advance Care Plan records preferences about
health, personal care and treatment goals. It may
be completed by discussion or in writing.
If you are able to make decisions about your
future healthcare, you can make an Advance Care
Plan by yourself or together with people that you
trust and/or who are important to you.
If you are not able to make decisions, an Advance
Care Plan can be made by a family member or
someone who knows you well, together with a
health professional. It should include your known
preferences about treatment.
Advance Care Directive
An Advance Care Directive is a way to say what
healthcare treatments you would like to have
or refuse, should you nd yourself in a position
where you are seriously ill or injured and unable
to make or communicate decisions about your
treatment and care.
An Advance Care Directive may include one or
more of the following:
• the person or people you would like to make
medical decisions for you if you are unable to
make decisions
• details of what is important to you, such as your
values, life goals and preferred outcomes
• the treatments and care you would like or refuse
if you have a life-threatening illness or injury.
Person Responsible
The Person Responsible is the person who will
make decisions for you if you do not have capacity
to do so. The Person Responsible is dened in
the NSW Guardianship Act 1987. The Person
Responsible may also be called the Substitute
Decision Maker.
The Person Responsible must follow your
Advance Care Directive when making decisions.
Common Terms
Making an Advance Care Directive 9
10 Making an Advance Care Directive
Enduring Guardian
An Enduring Guardian is a person or people who
have been legally appointed to make medical
or dental decisions for you. In some situations
a guardian may be appointed for someone,
but most people are able to choose their own
guardian. If you are 18 years of age or older
and have capacity, you can appoint one or two
Enduring Guardians.
When you appoint an Enduring Guardian, you can
decide what medical and dental decisions you
would like them to be able to make for you if you
do not have the capacity to make the decision
yourself.
Your Enduring Guardian must consider your
Advance Care Directive and previous expressed
preferences when making decisions.
Values statements
Some people may choose to record general
statements about what is important to them -
their values, beliefs and preferences - on their
Advance Care Directive or in their Advance
Care Plan. The following values statements are
provided as examples of what you may wish to
include in Section 2 of the form (there is no right
or wrong – it is entirely up to you what you record
to let others know):
Beliefs and values:
It is important for me to be able to communicate
in some way, even if I cannot speak.
Life has meaning when I can enjoy nature and
when I can practise my faith.
I value my privacy.
Physical or mental health concerns that you may
want considered:
I do not want to struggle to breathe.
I do not want to be in pain.
It is important to me that I spend time in my
garden.
Other information that you would like
considered:
I would like to stay at home as long as it is not too
hard on my family or the people caring for me.
I would not like to die at home.
I worry that my family or the people caring for me
will not know what to do.
I want owers in my room.
Cultural, spiritual and/or social care:
I would like prayer, religious or spiritual rituals in
my own language.
I would like my music to be played.
10 Making an Advance Care Directive
www.health.nsw.gov.au 1
SECTION 1: YOUR DETAILS AND YOUR PERSON RESPONSIBLE
Family name:
Given names:
Date of birth:
Address:
I have been provided with and read the ‘Making an Advance Care Directive’ information booklet.
Please tick if yes
I have legally appointed one or more people as my Enduring Guardian/s and they are aware of this
Advance Care Directive. Please tick if yes
ENDURING GUARDIAN 1 ENDURING GUARDIAN 2
Name:
Home phone number:
Mobile phone number:
Email address:
I have not appointed an Enduring Guardian
If, because of my medical condition, I am not able to understand and make decisions about my
treatment or can’t tell the doctors or my family, my Person Responsible as determined according to
the hierarchy within the NSW Guardianship Act (1987) is
PERSON 1 PERSON 2
Name:
Relationship:
Home phone number:
Mobile phone number:
Email address:
NSW Health Advance Care Directive (ACD)
* While not legally required, it is strongly recommended that a witness co-signs this Advance Care Directive and/or a health
professional witnesses you sign this form. Once completed this form is to be given to your Personal Responsible, Enduring
Guardian and medical professionals. You should keep a copy in a safe place and let others know where to nd it.
PERSONAL DETAILS
ENDURING GUARDIAN
PERSON RESPONSIBLE
www.health.nsw.gov.au 2
Information about your values is important as it is not possible for this document to cover all medical
situations. Information about what is important to you may help the person who is making decisions
on your behalf when they are speaking to the doctors about your care and treatment.
In this section you can include:
• things that are important to you at the end of life (your beliefs and values)
• issues that worry you, and
• personal, religious or spiritual care you would like to receive when you are dying.
If I am unable to communicate and not expected to get better:
• I would like my pain and comfort managed; and
• when deciding what treatments to give to me or not to give me, I would like the person/people
making health decisions for me to understand how the following would make me feel (initial
the box that is your choice)
Bearable
Unbearable
(I would like treatment
discontinued and to be
allowed to die a natural
death)
Unsure
1. If I can no longer recognise my family and
loved ones, I would nd life…
2. If I no longer have control of my bladder
and bowels, I would nd life…
3. If I cannot feed, wash or dress myself I
would nd life…
4. If I cannot move myself in or out of bed and
must rely on other people to reposition
(shift or move) me, I would nd life…
5. If I can no longer eat or drink and need to
have food given to me through a tube in my
stomach I would nd life…
6.
If I cannot have a conversation with others
because I do not understand what people are
saying, I would nd life…
SECTION 2: PERSONAL VALUES ABOUT DYING
If you do not want to complete this section, you should sign the bottom of this section
VALUES
www.health.nsw.gov.au 3
At the end of my life when my time comes for dying, I would like to be cared for, if possible
(initial the box of your choice)
At home
In a hospital
Other location (e.g hospice, residential aged care –
please provide details)
I do not know. I am happy for my Person Responsible/family to decide
When my Person Responsible is making decisions about care at the end of my life, I would like
them to consider the statements below
If you need extra space please attach an additional page.
I do not want to complete Section 2:
(Signature)
SECTION 2: PERSONAL VALUES ABOUT DYING
If you do not want to complete this section, you should sign the bottom of this section
www.health.nsw.gov.au 4
CPR
If I am not expected to recover, or if my life is unbearable as indicated in my Personal Values About
Dying, Section 2 on page 2, THEN, if my heart or breathing stops (please initial one box only)
I would accept CPR
OR
I would not accept CPR. Do not try to restart my heart or breathing
OTHER MEDICAL TREATMENTS
If I am not expected to recover, or if my quality of life is unbearable as indicated in the table my
Personal Values About Dying, Section 2 on page 2 and 3, THEN the following treatments would
be UNACCEPTABLE to me (initial the box/boxes that apply to your wishes)
Articial ventilation through a tube (also called ‘life support’,
‘breathing machine’)
Renal dialysis - (kidney function replacement)
Life prolonging treatments that require continuous administration of drug
OTHER (e.g. food and uid through a tube). Please list below:
Even if I am expected to get better I would never want the following medical treatments:
I do not want to complete Section 3:
(Signature)
This section applies to when you are unable to make or communicate decisions about your health
care and medical treatment, including CPR.
If you are able to communicate you will be included in decisions about your care.
If you do not want to complete this section, you should sign the bottom of this section
SECTION 3: DIRECTIONS ABOUT MEDICAL CARE
Resuscitation (CPR)
CPR refers to medical procedures that may be used to try to start your heart and
breathing if your heart or breathing stops. It may involve mouth to mouth resuscitation,
very strong pumping on your chest, electric shocks to your heart, medications being
injected into your veins and/or a breathing tube being put into your throat.
www.health.nsw.gov.au 5
My wishes about organ, tissue and body donation for transplantation following my death are
(initial your choice for each statement)
Yes No
I would like to donate my organs and tissues for transplantation
following my death.
I have discussed my organ and tissue donation wishes with my family
and friends and they are aware of my decision.
I would like to, or have already made arrangements to, donate my body
for education and/or scientic research.
Antemortem interventions are procedures to determine, maintain or improve the viability of
tissue.
Antemortem interventions for organ donation (are treatment/s immediately before my death only
for the purpose of organ donation (initial the box of your choice)
Yes No
It is my wish to donate my organs for transplantation after my death. If I
am dying, I consent to the doctors providing treatments for my organs
before my death (including articial
ventilation, insertion of intravenous
lines and administration of medications) intended only
for the purpose of
enabling me to donate my organs and tissue for transplantation.
I do not want to complete Section 4:
(Signature)
If you do not want to complete this section, you should sign the bottom of this section
SECTION 4: SPECIFIC REQUESTS FOR ORGAN, TISSUE
AND BODY DONATION
ORGAN, TISSUE AND BODY DONATION
ANTEMORTEM INTERVENTIONS FOR ORGAN DONATION
www.health.nsw.gov.au 6
PERSONAL DETAILS
By signing this document, I conrm that:
• I have read the accompanying information booklet, or had the details explained to me.
• I understand the facts and choices involved, and the consequences of my decisions.
• I am aware that this Advance Care Directive will be used in the event that I cannot make or
communicate my own health care decisions. If I am able to communicate, I will be asked to
make decisions about my care.
• I have completed this Advance Care Directive of my own free will.
/ /
(Signature) (Date)
DETAILS OF WITNESS*
I conrm that signed this document on / /
Signed: Name (please print):
Address: Phone:
TREATING HEALTH PROFESSIONAL*
Name: Designation:
Address:
Phone:
Email:
I conrm that I had no reason to doubt the capacity of the person
I conrm that
had capacity
and was aware of the implications of the information in this Advance Care Directive. (Medical
ofcer only)
/ /
(Signature) (Date)
SECTION 5: AUTHORISATION
* While not legally required, it is strongly recommended that a witness co-signs this Advance Care Directive and/or a health
professional witnesses you sign this form. Once completed this form is to be given to your Personal Responsible, Enduring
Guardian and medical professionals. You should keep a copy for yourself in a safe place and let others know where to nd it.
