GUARDIANSHIP AND ADMINISTRATION REGULATIONS 2005

Western Australian Consolidated Regulations

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GUARDIANSHIP AND ADMINISTRATION REGULATIONS 2005 - SCHEDULE 2

[r. 7]

[Heading inserted in Gazette 15 Sep 2009 p. 3594.]

Advance Health Directive

Notes:

• To make an advance health directive, you must be 18 years of age or older and have full legal capacity . ¹

• A person who makes an advance health directive is called “the maker”.

This advance health directive is made under the Guardianship and Administration Act 1990 Part 9B on

the .......................................... day of ........................................... 20.....................

by ............................................................................................................................

(maker’s full name)

of ............................................................................................................................

(maker’s residential address)

born on ...................................................................................................................

(maker’s date of birth)

This advance health directive contains treatment decisions in respect of my future treatment.

A treatment decision in this advance health directive operates in respect of the treatment to which it applies at any time I am unable to make reasonable judgments in respect of that treatment.

Notes about treatment decisions:

• Treatment is any medical, surgical or dental treatment or other health care (including palliative care and life sustaining measures such as assisted ventilation and cardiopulmonary resuscitation). ²

• A treatment decision is a decision to consent or refuse consent to the commencement or continuation of any treatment. ³

• A treatment decision operates only in the circumstances that you specify . ⁴

• Treatment to which you consent in this advance health directive can be provided to you.

• Treatment to which you refuse consent in this advance health directive cannot be provided to you.

• Your enduring guardian or guardian or another person cannot consent or refuse consent on your behalf to any treatment to which this advance health directive applies. ⁵

1. Treatment decision

In the following circumstances:

.................................................................................................................................

I consent / refuse consent (cross out and initial one of these)

to the following treatment:

.................................................................................................................................

2. Treatment decision

In the following circumstances:

.................................................................................................................................

I consent / refuse consent (cross out and initial one of these)

to the following treatment:

.................................................................................................................................

3. Treatment decision

In the following circumstances:

.................................................................................................................................

I consent / refuse consent (cross out and initial one of these)

to the following treatment:

.................................................................................................................................

Notes for maker about signing and witnessing:

• If you are physically incapable of signing this advance health directive, you can ask another person to sign for you. You must be present when the person signs for you. ⁶

• Two (2) witnesses must be present when you sign this advance health directive or when another person signs for you. ⁷

• Each of the witnesses must be 18 years of age or older and cannot be you or the person signing for you (if applicable).

• At least one of the witnesses must be authorised to witness statutory declarations. For a list of people who are authorised to witness statutory declarations, see the Oaths, Affidavits and Statutory Declarations Act 2005 . ⁸

• The witnesses must also sign this advance health directive. Both witnesses must be present when each of them signs. You and the person signing for you (if applicable) must also be present when the witnesses sign . ⁷

Signed by:

.................................................................................................................................

(maker’s signature)

Witnessed by a person authorised to witness statutory declarations:

.................................................................................................................................

(authorised witness’s signature)

.................................................................................................................................

(authorised witness’s full name)

.................................................................................................................................

(authorised witness’s address)

.................................................................................................................................

(occupation of authorised witness)

.................................................................................................................................

(date)

and by another person:

.................................................................................................................................

(other witness’s signature)

.................................................................................................................................

(other witness’s full name)

.................................................................................................................................

(other witness’s address)

.................................................................................................................................

(date)

Optional statement about legal or medical advice

Notes about statement:

• You are encouraged (but are not required) to seek legal or medical advice before making this advance health directive . ⁹

• If you wish to indicate that you have obtained legal or medical advice and wish to identify the person who gave you the advice, complete the relevant part of the statement.

• If you wish to indicate that you have obtained legal or medical advice but do not wish to identify the person who gave you the advice, cross out and initial the relevant part of the statement.

• If you do not wish to indicate whether or not you have obtained legal or medical advice, you may (but do not have to) cross out and initial the statement.

• If you do not wish to obtain legal or medical advice, you may (but do not have to) cross out and initial the statement.

• You do not have to say anything in this advance health directive about whether or not you have sought or obtained legal or medical advice. You can leave the statement blank and do not have to cross out or initial any part of it.

Before making this advance health directive, I obtained legal advice about making it.

I obtained that legal advice from ...........................................................................

.................................................................................................................................

(Details of person who provided legal advice)

Before making this advance health directive, I obtained medical advice about making it.

I obtained that medical advice from .......................................................................

.................................................................................................................................

(Details of person who provided medical advice)

Optional statement about enduring power of guardianship

Notes about statement:

• If you wish to indicate that you have made an enduring power of guardianship, put a tick ( Π ) or cross ( Ο ) in the box next to the statement.

• You do not have to say anything in this advance health directive about whether or not you have made an enduring power of guardianship. You can leave the box next to the statement blank.

I have made an enduring power of guardianship. ≤

________________________________________________________________

¹ Guardianship and Administration Act 1990 (GAA Act) s. 110P
² GAA Act s. 3(1), definitions of life sustaining measure , palliative care and treatment
³ GAA Act s. 3(1), definition of treatment decision
⁴ GAA Act s. 110S(2)
⁵ GAA Act s. 110ZJ
⁶ GAA Act s. 110Q(1)(c)
⁷ GAA Act s. 110Q(1)(d) and (e) and (3)
⁸ Oaths, Affidavits and Statutory Declarations Act 2005 s. 12(6) and Sch. 2
⁹ GAA Act s. 110Q(1)(b) and (2) and 110QA

[Schedule 2 inserted in Gazette 15 Sep 2009 p. 3594‑97; amended in Gazette 18 Dec 2009 p. 5169.]

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