ACT Hospital and Aged Care Advance Care Planning Steps

The Gap Between Having Documents and Having Them Followed

Most families in Canberra discover the hard way that signing advance care documents and having them available in a clinical emergency are two entirely different problems. A Health Direction sitting in a drawer at home is legally binding under the Medical Treatment (Health Directions) Act 2006 if a treating health professional reasonably believes it complies with the Act and has not been revoked or changed — but a doctor who has never seen it cannot follow it.

The ACT's advance care planning framework splits across three instruments: the statutory Health Direction (binding treatment refusals), the Statement of Choices (non-binding values and preferences), and the Enduring Power of Attorney (substitute decision-maker appointment). The Health Direction and Statement of Choices need to be integrated into clinical systems, while the EPoA needs to be available to the attorney and relevant care providers before a hospital admission or aged care transition, not during one.

Registering Documents With Canberra Hospital and Health Services

Canberra Health Services operates a centralised record through the MyDHR patient portal. You can upload certified copies of your Health Direction and Statement of Choices directly via MyDHR, or email scanned copies to the CPF scanning registry. The documents are then flagged on your clinical record, so emergency department staff and ward teams at Canberra Hospital can access them.

What MyDHR does not store is your EPoA. The EPoA is a legal instrument, not a clinical one — it tells clinicians who can make decisions on your behalf, not what decisions to make. However, noting the existence and location of your EPoA in your Statement of Choices (which MyDHR does hold) creates a practical breadcrumb trail for clinical teams.

You can also upload your Health Direction to My Health Record (the national digital health record), where it may be available to healthcare providers in other jurisdictions who have access to your record. This is particularly important for cross-border situations — if you are transferred from Canberra Hospital to a NSW facility, an ACT-only MyDHR record will not follow you, but a My Health Record entry may be available to a provider with access.

Integrating Documents With Aged Care Facilities

When transitioning a parent into residential aged care in the ACT, the facility's intake process should include a review of advance care planning documents. In practice, this step is often rushed or skipped.

Before admission, provide the facility with certified copies of all three documents: the Health Direction, the Statement of Choices, and the EPoA. Ask the facility to confirm in writing that the documents have been placed on the resident's clinical file. The aged care provider needs to know:

• Which treatments the resident has refused in their Health Direction
• Who holds EPoA for healthcare decisions (and their contact details)
• What values and preferences are recorded in the Statement of Choices

If the resident has not executed an EPoA and loses decision-making capacity after entering aged care, the Guardianship and Management of Property Act 1991 allows health professionals to appoint a "Health Attorney" from a statutory hierarchy of family members. But a Health Attorney has a critical limitation: they cannot authorise the withdrawal or withholding of life-sustaining treatment. If a treatment-refusal decision is needed, the matter must be referred to the Public Trustee and Guardian and potentially to ACAT — an outcome most families want to avoid.

What Happens During an Emergency Admission

If an ambulance brings you to the Canberra Hospital emergency department, clinicians may check MyDHR and My Health Record for any available advance care documents. If nothing is found, they may treat according to standard clinical protocols — which can include providing available life-sustaining treatment.

Your family members cannot verbally override this default. Even if they know your wishes, their verbal instructions do not by themselves establish the patient's Health Direction. The treating team needs a valid Health Direction in a form it can verify to withhold or withdraw treatment.

This is why proactive registration matters. The time to upload documents is months before a crisis, not while a family member is searching through filing cabinets at 2 a.m.

Palliative Care and Hospice Transfers

Clare Holland House (Canberra's specialist palliative care facility) and Calvary Public Hospital both have established advance care planning intake processes. When a patient is referred for palliative care, the clinical team reviews existing documents and, if none exist, initiates a conversation about completing them.

If your parent is being admitted to palliative care, this is often the last practical opportunity to put documents in place. Decision-making capacity can decline rapidly once symptom management becomes the primary clinical focus. Bring any existing documents to the first palliative care team meeting, and confirm they are on the clinical file.

The Practical Checklist

Before any hospital admission, aged care transition, or palliative care referral:

1. Upload your Health Direction and Statement of Choices to MyDHR
2. Upload your Health Direction to My Health Record (for cross-border access)
3. Give certified copies of all three documents to the facility or hospital ward
4. Confirm the EPoA holder's contact details are on the clinical file
5. Ask the facility to acknowledge receipt in writing

The ACT Advance Directive & Living Will Kit includes a storage and distribution log to track exactly which institutions hold copies of your documents — so nothing falls through the cracks when a clinical decision needs to be made quickly.

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