ADVANCE CARE DIRECTIVE 
FOR CARE AT THE END OF LIFE (TASMANIA)

This ADVANCE CARE DIRECTIVE will be used to guide future medical decisions ONLY when you lose the ability to make or communicate your medical treatment decisions yourself. In this event, your PERSON RESPONSIBLE will make medical treatment decisions on your behalf, in consultation with the treating doctors responsible for your care at the time. Medical treatment decisions will be made taking into account your expressed wishes, and where these are not known, in your best interests. 

If a person lacks the capacity to understand and complete this form for themselves it may be completed by their legally appointed Enduring Guardian or by a “Person Responsible”. Where possible the Person Responsible does so in of knowledge of the expressed wishes of the Person Concerned before they lost capacity, or in what are believed to be the best interests of the Person Concerned. 

Where “I/my” is shown in this document, it means the Person Concerned 

THIS IS THE ADVANCE CARE DIRECTIVE FOR	<PtFullName>	
Date of Birth	<PtDoB>	
of  (address)	<PtAddress>  	

AND IS BEING COMPLETED BY		 self, or		 Person Responsible, please write your name and address:	

	

(Note: tick the ‘self’ box above if you are completing this ACD in your own writing or if another person is writing down what you tell them). If you are writing on behalf of someone who lacks decision-making capacity, you should enter your own name next to ‘Person Responsible’

I request that the stated wishes for my End of Life Care and medical care generally, recorded below,
are respected by my PERSON RESPONSIBLE or Enduring Guardian, and by any doctors involved in
my care.

MY VALUES AND BELIEFS 
(please detail here the things that matter to you, which you think may be relevant when you can no longer speak for yourself, including any specific religious, spiritual or other practices to be observed)

	

PLANS FOR LIMITATION OF MEDICAL TREATMENT AT THE END OF MY LIFE 
q	I request that treatment aimed at prolonging life be withheld or stopped, and appropriate care be provided forsymptom management, quality of life, comfort and dignity (ie, palliative care), if at some future time it is the opinionof the treating team responsible for my medical care that:

• significant recovery is highly unlikely, or
• the outcome of such treatment would be a permanent coma, or
• any other medical outcome that is unacceptable to me (detail here).

	

PREFERENCES FOR TREATMENT TO MAINTAIN MY QUALITY OF LIFE 
(detail here any outcomes that would be particularly unacceptable to you: e.g. I fear being unable to speak and move myself, or, Being able to communicate with my family is very important to me so I would not want life-prolonging treatment if I was unable to talk to them, or, I do not want to be put on a breathing machine, or I do not want to be fed through a tube. Please note: Good palliative care may include antibiotics, operations, fracture repairs and other treatment intended only to maintain your quality of life)

	

OTHER WISHES

	

If there is not enough room to write all your requests and wishes, please attach further pages as necessary. All additional pages need to be signed, dated and witnessed.

Name of person completing this document		

Signature:                                                                                   Date:	
 	
Are you a registered organ and tissue donor?   q Yes      q No		

Translator/Interpreter
I have provided a translation/interpretation in the _____________________ language, of the ACD form and
any verbal or written information given to the Person Concerned/Person Responsible by others at the time of
completion of this ACD.
Translator/interpreter signature ______________________________ Date ________________________
Translator/interpreter name, address and contact details _______________________________________
____________________________________________________________________________________

Witness 
It is assumed that a witness acts in good faith, and must: 

•	 Be over 18; 
•	 Be unrelated to the PERSON CONCERNED, and must not be a known beneficiary in that person’s will; 
•	 Confirm the identity of the PERSON CONCERNED and/or PERSON RESPONSIBLE 
•	 Believe that the person understands that this document is about medical treatment decisions and 
•	 Be confident that the person is under no duress or pressure 

The witness can be a registered health care professional, but cannot be a paid personal carer. 
Witness signature:                                       Date:	
	
Witness name, address and contact details	

I (write name here)		

have talked to, and given a copy of this Advance Care Directive to the following people and wish them to speak on my behalf should I not be able to understand or speak for myself: 

1. Person Responsible
q	I would like the following persons, if available, to be my Person Responsible (in order of
preference). If you have appointed an Enduring Guardian please leave this section blank and enter
details in the final section.

Name		
Telephone	 (home)	(mobile)	(work)	
Relationship		

2. Person Responsible
Name		
Telephone	 (home)	(mobile)	(work)	
Relationship		

I have given a copy of this	ACD to:	
GP		
Solicitor		
Enduring Power of Attorney		
Other		

Enduring Guardian		
q	I have completed the Guardianship & Administration Board forms and appointed		

(Name)	as my enduring guardian	
Telephone		(home)	(work)	(Mobile)	
Date Appointed		

I have also appointed
(Name)		
as my	  q joint or   q alternative Enduring Guardian	
Telephone		(home)	(work)	(Mobile)