This is an advance care plan for a person with insucient decision-making capacity to complete an
advance care direcve¹. This is not a form that is able to give legally-binding consent to, or refusal
of treatment. This plan can be used to guide substute decision-makers and clinicians when making
medical treatment decisions on behalf of the person, if the person does not have an advance care
direcve.
What is advance care planning?
A process of planning for future health care, for a me when the person is no longer able to make
their own health care decisions. It relates to a person’s future health care and medical treatments.
It may include conversaons about treatments they would or would not like to receive if they
become seriously ill or injured. It includes idenfying the person they want to make these decisions
and how they want those decisions to be made. It has many benets for the person (care aligned
with preferences), loved ones and treang clinicians.
When should this form be completed?
This form should only be completed if the person no longer has sucient decision-making capacity to
make or communicate their medical treatment decisions. This form is available for use in all Australian
states and territories, however the Australian Capital Territory, Queensland, and Victoria have exisng
recommended forms, see Table 1.
This form is not intended to replace or revoke a legally-binding advance care direcve. If the person
does have decision-making capacity, they should consider compleng an advance care direcve.
The voluntary compleon of an advance care direcve, when the person sll has decision-making
capacity, is preferable over the compleon of an advance care plan¹. The relevant advance care
direcve form from each state and territory is available at:
www.advancecareplanning.org.au/create-your-plan
Who should complete this form?
This form should be completed by a person’s recognised substute decision-maker(s), assigned
to the role by law or appointed by the person to make medical treatment decisions, see Table 2.
They should have a close and connuing relaonship with the person. It is intended that this form
will assist substute decision-makers and the treang team to make medical treatment decisions that
align with the decisions the person would have made in the same circumstances. This informaon can
be used in aged care, community, or hospital sengs.
Advance care plan for a person with insucient decision-making capacity
Instrucon Guide: page 1 of 3 www.advancecareplanning.org.au
Instrucon Guide
How to complete this form?
This form allows you to provide informaon about the values and preferences relang to future
medical treatment for a person who has lost the capacity to make their own decisions. The
informaon provided in this form should be guided by the person’s past choices and decisions,
and any previously expressed values and preferences. When compleng this form, you should
consider what decisions the person would have made in these circumstances, if they had the
decision-making capacity to do so.
When compleng this form, the following guiding principles should be used:
• When considering the person’s values, think about how they like to live their life, what they
enjoy doing, and what maers most to them, taking into account things they have said or
done in the past.
• Any previously expressed preferences or choices made relang to healthcare, medical
treatment, or life prolonging treatments², and type or locaon of care should be regarded.
• Any previously expressed views the person made about acceptable or unacceptable health
outcomes should be taken into account.
• Consideraon should be given to any observaons made in relaon to the person including
how they make decisions and what their priories and interests are.
How should this form be used?
Before relying on this form, the person’s clinicians should consider their legal obligaons relang to
consent of medical treatment decisions in the state or territory that they pracce in. They should be
sure that the person does, at the me that decisions must be made, lack the capacity to make those
decisions.
Where possible, the responsible clinicians should ascertain, the most up-to-date advance care
direcve for preferences for care and/or appointment of a substute decision-maker. The clinician
should also ensure that the person compleng this form is the most appropriate substute
decision-maker if no-one has been appointed.
The idenes of the person(s) lling out this form on behalf of the person with insucient decision-
making capacity to complete an advance care direcve should be assessed carefully. Anyone relying
on this form should be condent that the person(s) who completed this form truly represented the
person’s values and preferences.
How should this form be stored and shared?
Copies of the advance care plan should be shared with the person’s substute decision-maker(s),
aged care, community or hospital provider, treang clinicians, General Praconer and/or stored
in My Health Record.
Who to contact for further informaon?
Advance Care Planning Australia
Naonal Advance Care Planning Support Service: 1300 208 582
www.advancecareplanning.org.au
Instrucon Guide: page 2 of 3 www.advancecareplanning.org.au
Table 1. Exisng Advance Care Plans
State/Territory Document name
Australian Capital Territory Advance Care Plan Statement of Choices (No Legal Capacity)
Queensland Statement of Choices Form B
Victoria What I understand to be the person’s preferences and values
Table 2. Title of legally-binding Advance Care Direcves by state and territory
State/Territory Advance Care Direcve -
preferences for Care
Advance Care Direcve – appointment
of a substute decision-maker
Australian Capital
Territory
Health Direcon Enduring Power of Aorney
New South Wales Advance Care Direcve Appointment of Enduring Guardian
Northern Territory Advance Personal Plan Advance Personal Plan
Queensland Advance Health Direcve Advance Health Direcve/ Enduring Power
of Aorney
South Australia Advance Care Direcve Advance Care Direcve
Tasmania Advance Care Direcve Instrument Appoinng Enduring Guardian(s)
Victoria Advance Care Direcve Appointment of a Medical Treatment Decision
Maker
Western Australia Advance Health Direcve Enduring Power of Guardianship
Note: In the absence of a substute decision-maker appointment by the person, state and territory law assigns this role via
a hierarchy, with the excepon of Northern Territory.
Reference
1. Naonal framework for advance care planning documents. 2021. Australian Government,
Department of Health.
2. Advance Care Planning Australia. Life prolonging treatments. 2021. Available:
www.advancecareplanning.org.au/understand-advance-care-planning/life-prolonging-treatments
Disclaimer
This publicaon is general in nature and people should seek appropriate professional advice about
their specic circumstances, including advance care planning legislaon and policy in their state or
territory.
Instrucon Guide: page 3 of 3
www.advancecareplanning.org.au
(For person health record purposes, aach a label here)
Page 1 of 6
Full name:
Date of birth:
(dd/mm/yyyy)
Address:
The person with insucient decision-making capacity that this document applies to
If you are a health service or
aged care organisaon, add
your logo within this space.
FORM
Advance care plan for a person with insucient decision-making capacity
This is an advance care plan for a person with insucient decision-making capacity to complete an
advance care direcve¹. This is not a form that is able to give legally-binding consent to, or refusal of
treatment. This plan can be used to guide substute decision-makers and clinicians when making medical
treatment decisions on behalf of the person, if the person does not have an advance care direcve.
Queson 1
Full name:
Relaonship to the person:
Address:
The person compleng this document
Phone number:
I believe that I am this person’s legally recognised substute decision-maker:
If yes and appointed, please aach documentaon that provides evidence of this (see Table 2 of the
Instrucon Guide).
Yes No Unknown
Queson 2
UR Number:
Date of birth:
(dd/mm/yyyy)
Surname:
Given name(s):
Form: Advance care plan for a person with insucient decision-making capacity
If no, the person’s legally recognised substute decision-maker should complete and sign the form.
Page 2 of 6
Full name:
Relaonship to the person:
Addional contributor to this document, if applicable
If yes and appointed, please aach documentaon that provides evidence of this, (see Table 2 of the
Instrucon Guide).
This person is a legally recognised substute decision-maker:
Yes No Unknown
Queson 3
Does the person have an advance care direcve? (see Table 2 of the Instrucon Guide)
Yes (please aach copy to this form) No Unknown
If you answered yes, was the person’s advance care direcve considered when compleng this form?
Yes
No Please provide reasons:
Queson 4
(For person health record purposes, aach a label here)
UR Number:
Date of birth:
(dd/mm/yyyy)
Surname:
Given name(s):
Form: Advance care plan for a person with insucient decision-making capacity
Advance care plan
for a person with insucient
decision-making capacity
Address:
Phone number:
If no, the person’s legally recognised substute decision-maker should be listed above as the person
compleng this document.
The person’s main health condions (list all relevant condions)
Queson 5
Page 3 of 6
The person’s values (as I best understand them)
I believe the things that are most important to this person are:
(Note: consider the guiding principles and the person’s desire for independence, social connecons, emoonal
well-being, funconal mobility, and parcipaon in acvies. An example statement might be ‘they would like
to be able to have meaningful interacons with family and loved ones such as conversaons, eang together,
and celebrang special occasions’).
(For person health record purposes, aach a label here)
UR Number:
Date of birth:
(dd/mm/yyyy)
Surname:
Given name(s):
Form: Advance care plan for a person with insucient decision-making capacity
Advance care plan
for a person with insucient
decision-making capacity
(Note: consider the guiding principles and their desired funconal requirements, emoonal well-being, and willingness
to receive medical intervenons. An example statement might be ‘being fully dependent on care and unable to interact
with family and loved ones’).
I believe the things that would be unacceptable health outcomes to this person are:
I believe the things that would be acceptable health outcomes for this person are:
(Note: consider the guiding principles and their desired funconal requirements, emoonal well-being, and willingness
to receive medical intervenons. An example statement might be ‘living with equipment and support for the acvies
of daily living; being dependent on care if they can interact with family and loved ones’).
Queson 6
Page 4 of 6
I believe the things that this person is hoping to do now and in the future are:
(Note: consider the guiding principles and their desire for independence, social connecons, emoonal well-being,
funconal mobility, and parcipaon in acvies. An example statement might be ‘live in their own home with support
of family and paid carers; read novels or the paper daily’).
Queson 6 connued
(For person health record purposes, aach a label here)
UR Number:
Date of birth:
(dd/mm/yyyy)
Surname:
Given name(s):
Form: Advance care plan for a person with insucient decision-making capacity
Advance care plan
for a person with insucient
decision-making capacity
Other values that are important to know about this person
The person’s treatment preferences (as I best understand them)
If this person became very unwell with either an expected or unexpected deterioraon with no
hope of an acceptable outcome, the following statement best represents their views:
(ck one box only)
Living as long as possible is their major goal no maer the outcome OR
They would want life prolonging treatment that may extend their life, but not if it is likely
to result in an unacceptable health outcome OR
They would not want life prolonging treatment that may extend their life OR
Not sure
(Note: Life prolonging treatment includes but is not limited to Cardiopulmonary Resuscitaon (CPR),
arcial venlaon, tube feeding, surgery, oral or intravenous anbiocs and/or dialysis.)
Queson 7
Advance care plan
for a person with insucient
decision-making capacity
Page 5 of 6
I believe if this person is nearing death, they would like the following to be considered.
(Example: place of death, presence of family or loved ones, music, religious, cultural or spiritual
support).
Queson 7 connued
Are there any life prolonging or parcular treatments that the person would not want to receive?
(For person health record purposes, aach a label here)
UR Number:
Date of birth:
(dd/mm/yyyy)
Surname:
Given name(s):
Form: Advance care plan for a person with insucient decision-making capacity
Addional notes
Advance care plan
for a person with insucient
decision-making capacity
Page 6 of 6
Legally recognised substute decision-maker
By signing this form, I conrm this is an accurate record of this person’s values and preferences as
I understand them at the me of compleng this form.
Full name:
Signature:
Date:
(dd/mm/yyyy)
By signing this form, I cerfy to the best of my knowledge the person compleng this form is
an appropriate person to represent the values and preferences of the person with insucient
decision-making capacity.
Full name:
Signature:
Date:
(dd/mm/yyyy)
Signing
The person’s treang doctor or registered health professional
(For person health record purposes, aach a label here)
UR Number:
Date of birth:
(dd/mm/yyyy)
Surname:
Given name(s):
Form: Advance care plan for a person with insucient decision-making capacity
Please ck all to indicate your understanding of the following statements.
I am of the reasonable belief that a person for whom this form applies does not have
decision-making capacity to make medical treatment decisions.
I understand that this document does not provide legally-binding consent to, or refusal of
treatment but may be used to guide substute decision-makers and clinicians to make medical
treatment decisions.
I understand that if the person does have an advance care direcve, the values and preferences
expressed in a valid advance care direcve will be respected, if their medical treatment
decisions are clinically indicated and appropriate.
I understand that this person may sll receive care for symptoms such as pain and to alleviate
suering regardless of the values or preferences stated in this form and that an advance care
direcve or advance care plan cannot refuse such measures.
I understand that I am documenng this person’s values and preferences honestly, to the best
of my knowledge and without intent to cause harm.
I understand this form should be reviewed if the persons condion changes, can be cancelled
or changed whenever needed.
Queson 8