Advance care planning – glossary of terms

Advance Care Directives is a catch-all term to refer to the instruments which are recognised in each Australian jurisdiction under advance care directive legislation or common law.

They are voluntary, person-led documents completed and signed by a competent person that focus on an individual’s values and preferences for future care decisions, including their preferred outcomes and care.

They come into effect when an individual loses decision-making capacity. Advance Care Directives can also appoint substitute decision-makers who can make decisions about health or personal care on the individual’s behalf. Advance Care Directives are focused on the future care of a person, not on the management of his or her assets.

Advance Care Directives are recognised by specific legislation (statutory) or under common law (non-statutory).

• Common law (non-statutory) Advance Care Directive: a structured document that is completed and signed by a competent adult and that is not a legislated statutory document. In Western Australia, this includes the My Values and Wishes Form: Planning for my future care.
• Statutory Advance Care Directive: a signed document that complies with the requirements set out by a jurisdiction’s legislation. In Western Australia, this includes an Advance Health Directive and Enduring Power of Guardianship which comply with the Guardianship and Administration Act 1990.

Documents that capture a person’s beliefs, values and preferences in relation to future care decisions, but which do not meet the requirements for statutory or common law recognition due to the person’s lack of competency, insufficient decision-making capacity or lack of formalities (such as inadequate person identification, signature and date).

A voluntary process of planning for future health and personal care whereby the person’s values, beliefs and preferences are made known to guide decision-making at a future time when that person cannot make or communicate their decisions. 

An Advance Health Directive (AHD) is a voluntary, person-led, legal document that enables a person to make decisions now about the treatment they would want – or not want – to receive under specific circumstances if they ever became sick or injured and were incapable of communicating their wishes. In such circumstances, their AHD would effectively become their voice.

The term 'treatment' includes medical, surgical and dental treatments, including palliative care and life-sustaining measures.

An AHD would come into effect only if it applied to the treatment a person required and only if the person was unable to make reasoned judgements about a treatment decision at the time that the treatment was required.

Artificial feeding is provided when a person is unable to eat. It involves the administration of nutrition through a feeding tube which may be passed into the stomach from the nose or directly into the stomach through the abdominal wall.

The ability to make a decision for oneself.

Decision-making capacity can be assessed by trained professionals, and its assessment depends on the type and complexity of the decision to be made.

Capacity assessment does not assess whether the decision is considered “good” or “bad” by others such as health practitioners or family, but rather considers the person’s ability to make a decision and comprehend its implications.

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.

By default, people are assumed to have capacity, unless there is evidence to the contrary.

Full legal capacity refers to the capacity to make a formal agreement and to understand the implications of statements contained in that agreement.

Emergency measures to keep the heart pumping (by chest compression and/ or use of a defibrillator) and assisted ventilation when the heart and/or breathing have stopped.

Written or verbal communications describing a person’s wishes about treatment to be provided or withheld in specific situations in future. There are no formal requirements in relation to Common Law Directives. It can be difficult to legally establish whether a Common Law Directive is valid and whether it should or should not be followed. For this reason, Common Law Directives are not recommended for making treatment decisions. 

End-of-life is the timeframe during which a person lives with, and is impaired by, a life-limiting/ fatal condition, even if the prognosis is ambiguous or unknown. Those approaching end-of-life will be considered likely to die during the next 12 months.

Care needed for people who are likely to die in the next 12 months due to progressive, advanced or incurable illness, frailty or old age.

An enduring power of attorney is a legal agreement that enables a person to appoint a trusted person - or people - to make financial and property decisions on their behalf. 

An Enduring Power of Guardianship is a legal document that authorises a person of an individual’s choice, to make important personal, lifestyle and treatment decisions on their behalf should they ever become incapable of making such decisions themselves. This person is known as an enduring guardian.

An enduring guardian could be authorised to make decisions about things such as where the person live, the support services they have access to and the treatment they receive.

General Practitioners - Australia's family doctors - are specialists in their own right. A GP is trained to treat the whole person and to care for people of all ages, all walks of life, and with all types of medical issues and concerns.

Goals of Patient Care is a clinical care planning process used during an admission to hospital or other care facility. It helps to determine which treatments would be useful for a person, if there was deterioration in their condition. The Goals of Patient Care process uses a shared decision-making approach. A conversation is held with the person, their family or carer(s) and is led by their hospital doctor. Together, they decide which treatments would be appropriate and acceptable for the person.

The Goals of Patient Care process uses a clinical document written by the healthcare team to record information about the shared-decisions that have been made following the goals of care discussions between a person, their doctor or health care team and their family or carer(s).

Goals of Patient Care documents are not the same as advance care planning documents for legal purposes. Advance care planning documents are written by the person and are covered by law.

A person appointed by the State Administrative Tribunal to act on an individual’s behalf. The State Administrative Tribunal determines which powers the guardian may use on the person’s behalf.

Health care can include medical treatment, life-sustaining treatment, surgery, mental health treatment, medications, dental treatment, maternity care, emergency care, nursing care, podiatry, physiotherapy, optometry, psychological therapy, Aboriginal health care, occupational therapy, and other services provided by registered health practitioners such as traditional Chinese medicine.

Any registered person who practises a discipline or profession in the health area that involves the application of a body of learning, including a person belonging to a profession specifically defined by legislation.

Medical processes used when a person is unable to breathe for themselves. Intubation is the passage of a tube (usually through a person’s mouth) into their lungs. Ventilation is the act of passing air through the tube.

People who identify themselves as lesbian, gay, bisexual, transgender, intersex, queer/ questioning, asexual and/or other diverse sexual orientations and gender identities.

A life limiting condition is a disease, condition or injury that is likely to result in death, but not restricted to the terminal stage when death is imminent.

A life-prolonging measure means a medical, surgical or nursing procedure directed at supporting or maintaining a vital bodily function that is temporarily or permanently incapable of independent operation, and includes assisted ventilation and cardiopulmonary resuscitation.

Any medicine given with the purpose of reducing pain. Pain medication may be given via a variety of means including by mouth, injection or through a patch applied to the skin.

An approach that improves the quality of life of a person with a life-limiting illness or condition and their family members or carers through the prevention and relief of suffering. Palliative care recognises the person and the importance and uniqueness of their family or carer. It considers physical, social, financial, emotional and spiritual factors that can influence the experience and outcomes of having a life-limiting illness.

A statutory officer appointed under the Guardianship and Administration Act 1990 to protect and promote the rights of adults with a decision-making disability.

The judicial body which, under the Guardianship and Administration Act 1990, hears matters about the operation of Enduring Powers of Guardianship and Advance Health Directives.

An illness or condition that is likely to result in death. The terminal phase of a terminal illness means the phase of the illness reached when there is no real prospect of recovery or remission of symptoms (on either a permanent or temporary basis).

Any medical, surgical or dental treatment or other health care, including a life sustaining measure or palliative care. 

A decision to consent or refuse consent to the commencement or continuation of any treatment of the person. 

Urgent treatment means treatment urgently needed by a patient:

• to save the patient’s life
• to prevent serious damage to the patient’s health
• to prevent the patient from suffering or continuing to suffer significant pain or distress.