Your guide to advance care planning in Western Australia
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Documents related to your health and care
Values and Preferences Form: Planning for my future care
Type of document: Informal
What it is: A record of your advance care planning
discussions.
Why it is useful: To let people know your values, preferences
and wishes. 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.
What is included: Questions are the same as the ‘Values’
section of the Advance Health Directive (see below). 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.
Enduring Power of Guardianship (also called an EPG)
Type of document: Legal
What it is: A legal document that authorises a person to make
important 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.
When it is used: An Enduring Power of Guardianship is only
used if you become unable to make decisions or tell people
what you want.
What is included: An enduring guardian could be authorised to make decisions
about things such as:
• where you live
• the support services you have access to
• the treatment(s) you receive.
An enduring guardian cannot make property or nancial decisions on your behalf.
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Enduring Power of Guardianship
This Enduring Power of Guardianship is made under the Guardianship and Administration Act 1990
Part 9A
on the
________________________________________________
day of
__________________________________________________
20
_______
by (appointor’s full name)
______________________________________________________________________________________________
of (appointor’s residential address)
____________________________________________________________________________________
______________________________________________________
born on (appointor’s date of birth)
______________________________
This Enduring Power of Guardianship has effect, subject to its terms, at any time I am unable to make
reasonable judgments in respect of matters relating to my person.
1 Appointment of enduring guardian(s)
1A
Sole enduring guardian
I appoint (appointee’s full name)
_______________________________________________________________________________________
of (appointee’s residential address)
___________________________________________________________________________________
___________________________________________________________________________________________
to be my enduring guardian.
1B
Joint enduring guardians
I appoint (appointee’s full name)
_______________________________________________________________________________________
of (appointee’s residential address)
___________________________________________________________________________________
_______________________________________________________________________________________________________________________________
and (appointee’s full name)
______________________________________________________________________________________________
of (appointee’s residential address)
___________________________________________________________________________________
____________________________________________________________________________________
to be my joint enduring guardians.
2 Appointment of substitute enduring guardian(s)
I appoint (appointee’s full name)
_______________________________________________________________________________________
of (appointee’s residential address)
___________________________________________________________________________________
____________________________________________________________
to be my substitute enduring guardian in substitution of
(enduring guardian’s name)
______________________________________________________________________________________________
I appoint (appointee’s full name)
_______________________________________________________________________________________
of (appointee’s residential address)
___________________________________________________________________________________
____________________________________________________________
to be my substitute enduring guardian in substitution of
(enduring guardian’s name)
______________________________________________________________________________________________
My substitute enduring guardian(s) is (are) to be my enduring guardian(s) in the following circumstances:
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Signing each page is not compulsory but may provide a safeguard against pages being substituted. Signature of
(appointor)
_____ ___________________________
(witness 1)
_____ ___________________________
(witness 2)
_______________________________
OR
1
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