Advance Care Planning for Palliative Care in the ACT

Why Palliative Care Is the Critical Planning Window

A referral to palliative care is often the moment when advance care planning shifts from something you will get around to eventually into something you need done this week. Decision-making capacity can deteriorate quickly once symptom management becomes the primary clinical focus, and the ACT's framework requires that all three planning instruments — Health Direction, Statement of Choices, and EPoA — are executed while you still have capacity to sign them.

Canberra's palliative care services include Clare Holland House (the ACT's specialist inpatient palliative care unit, operated by Calvary), Calvary Public Hospital's palliative care team, and Canberra Hospital's palliative care consultation service. Each has an advance care planning intake process, but the depth and consistency of that process varies. Arriving with your documents already completed puts you in control of the conversation rather than responding to a clinical checklist.

What Each Facility Needs From You

Clare Holland House

Clare Holland House in Barton is a 19-bed inpatient facility for patients whose symptoms cannot be managed at home. At admission, the clinical team reviews existing advance care planning documents and initiates a goals-of-care conversation.

If you have already executed a Health Direction, bring the original or a certified copy. The palliative care team will review your treatment refusals and discuss how they should be reflected in the facility's clinical care plan. If your Health Direction refuses CPR, intubation, or artificial nutrition, ask the team how those refusals will be reflected in the facility's clinical care plan.

If you do not have a written Health Direction, the palliative care team can facilitate a conversation about your treatment preferences — but they cannot execute the document for you. You will need to arrange witnessing independently (two adult witnesses, in each other's presence).

Calvary Public Hospital

Calvary's palliative care team operates within the broader hospital environment. Advance care documents need to be flagged not just with the palliative care team but on the general hospital clinical record, because if you deteriorate and require emergency intervention, the on-call team — not the palliative care team — will be the first responders.

Upload your Health Direction and Statement of Choices to MyDHR before admission. Provide a separate hard copy to the palliative care clinical nurse coordinator.

Canberra Hospital

Canberra Hospital's palliative care consultation service sees patients across the hospital's wards. The same advice applies: upload to MyDHR, provide hard copies to the ward team, and confirm that a resuscitation plan consistent with your Health Direction has been placed on your clinical chart.

The Statement of Choices Matters Most in Palliative Care

In the acute hospital environment, the Health Direction — with its legally binding treatment refusals — is the most critical document. In palliative care, the Statement of Choices often becomes more important day to day.

Palliative care decisions are rarely binary. They involve questions like: Would you prefer to manage pain aggressively even if it reduces consciousness? Do you want to be transferred to hospital if a new complication arises, or remain at Clare Holland House for comfort care? Are there specific people you want present (or absent) during your final hours?

The Statement of Choices captures these values. It is not legally binding, but palliative care teams rely on it heavily — it fills the space between the Health Direction's hard refusals and the moment-to-moment clinical decisions that do not rise to the level of a formal treatment refusal.

Timing: Before Capacity Declines

The window for completing advance care documents is smaller than most families expect. Early in a palliative care admission, the patient is often still lucid and engaged. Within weeks — sometimes days, depending on the illness trajectory — pain medications, fatigue, or disease progression can impair decision-making capacity.

If capacity is already fluctuating, a medical practitioner can provide a written cognitive assessment confirming that the patient had capacity at the moment of signing. This assessment is not required by law, but it provides strong evidence if the document is later challenged.

For families supporting a parent through palliative care: if your parent has not yet completed their advance care planning documents, the first palliative care team meeting is the time to raise it. Do not wait for the team to bring it up — some teams do, some do not, and by the time someone asks, the window may have closed.

The EPoA in the Palliative Context

Once the patient loses decision-making capacity, the attorney appointed under the EPoA makes healthcare decisions that are not covered by the Health Direction, within the powers granted and statutory limits. This includes decisions about:

• Transferring between care settings (home, hospital, hospice)
• Consenting to new treatments or clinical trials
• Managing visitors and communication preferences
• Arranging discharge or transition to residential aged care

The Health Direction addresses what the patient refuses. The EPoA attorney handles other healthcare matters within the powers granted and statutory limits. Without an EPoA, the default Health Attorney hierarchy kicks in — and a Health Attorney cannot authorise the withdrawal of life-sustaining treatment, which can create exactly the situation the patient was trying to avoid.

The ACT Advance Directive & Living Will Kit includes all three planning instruments with guidance specific to palliative care scenarios, including a values conversation worksheet designed for the goals-of-care conversation that palliative care teams initiate at admission.

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