Information for Health Providers


If at any time a person loses decision making capacity, either temporarily or permanently, having an Advance Care Plan in place provides a pathway for professionals, patient, carers and caregivers to offer quality care in line with the patient’s wishes. People with progressive, life-limiting conditions such as cancer, chronic disease or facing an early diagnosis of cognitive impairment or admission to a residential aged care facility are most likely to plan.However Advance Care Planning is relevant for every person’s age and life stage.

Capital Health Network acknowledges the work of the Rural Health Foundation for the production of this video and permission for its use.

Notable Australian experts on Advance Care Planning Dr Peter Saul and Dr Colleen Cartwright share valuable insights in these links.

A National Framework for Advance Care Directives outlines goals of policy and best practice in the context of differing national laws and practices. There is Australia wide consumer and professional information and support available at the Advance Care Planning national website. This website covers State and Territory current laws and practice. The content covers Advance Care Planning or Advance Care Directives and the legal appointment of ‘attorneys’ or ‘substitute decision makers'

Decision Assist  is an exciting new program that is enhancing the delivery of Advance Care Planning and specialist palliative care to older Australians, by providing education and support to GPs and aged care staff nationally. Funded by the Australian Government, it includes a 24/7 telephone advisory service for health professionals, specialised workshops, improved linkages between palliative care and aged care services, and a dedicated website featuring the latest information and advice about advance care planning and palliative care.

Guidance and assistance with Advance Care Planning requires a fundamental understanding that advance care planning is a ‘process’ not a one off occurrence. The individual may, at any time, elect to develop a new Advance Care Plan to reflect any changes to their health status  and/or fluctuations in their life circumstance. The legal process of nominating a Substitute decision makers  and the conversations with loved ones is a priority for beginning the advance care planning process.


The fundamental right for every competent person to consent to and to refuse medical treatment is the basis for Advance Care Planning.

The Statute law in the ACT covering Advance Care Planning is:

  • Powers of Attorney Act 2006: This Act covers the Enduring Power of Attorney whereby a person legally appoints a person or persons to act on their behalf if they either temporarily or permanently lose decision making capacity. The functions cover health and/or personal care and/or financial and property matters.
  • Medical Treatment Act (Health Directions) Act 2006: This Act provides for directions about withholding or withdrawing of medical treatment. Health Direction form

Common Law

  • An Advance Care Plan: Statement of Choices: is not a legal document under Statute Law but is recognised under Common Law.

Practitioner Resources

Resources available to assist practitioners with the process of Advance Care Planning can be found at the RACGP, AMA and Palliative Care web sites.

Experienced practitioners, aware of the predictive nature, risks and pathways of chronic and terminal diseases are primed to assist those willing to plan in advance to understand their prognosis and prepare accordingly. The Care Search Evidence base, Care search GP Hub, and further Palliative Care specific information provide links to evidence to assist best practice.

Alzheimer’s Australia  “Planning for end of life with dementia” by Dr Colleen Cartwright  discusses the issue of dementia and the positives of an early diagnosis, allowing time for establishing good supports, understanding and planning to cope with the progression of the disease .The person who has been diagnosed with dementia can take part in that planning, thus ensuring that their wishes for their end-of-life care are known.

Residential Aged Care Facilities

The medical care of older persons in residential aged care the RACGP Silver book supports Advance Care Planning in the long term care scenario. It provides an opportunity for residents and their family to discuss prognosis and future treatment choices. Communication between the resident, their family, the staff and their treating General Practitioner means that difficult decisions about care are not made at the last minute. This allows the resident’s values and wishes to be known, and followed, in treatment and care decisions, preventing unnecessary traumatic transfers to hospital.

Further information

There are some great Australian and International websites that are worth a look (See under Links on the home page).

Capital Health Network is grateful to the Winnipeg Regional Health Authority  for their assistance with this project.

Advanced Care Planning
Public Trustee and Guardian
ACT Government Health
Capital Health Network

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