Advance Care Directives, VAD, Palliative Care, and Organ Donation in South Australia

What the ACD Actually Controls

Your South Australia Advance Care Directive is a powerful document, but it has specific boundaries. Understanding what falls inside and outside its legal scope prevents the kind of confusion that surfaces at the worst possible moment — when you've lost the capacity to clarify your intentions.

The Advance Care Directives Act 2013 authorises your ACD to cover healthcare decisions, lifestyle preferences, residential accommodation choices, and the appointment of substitute decision-makers. The redesigned March 2024 form also includes a section for organ and tissue donation preferences. But some end-of-life decisions operate under entirely separate legislation, and assuming your ACD handles everything can leave critical gaps.

Voluntary Assisted Dying: A Separate Pathway

South Australia's Voluntary Assisted Dying Act 2021 established a distinct, regulated pathway for people with a terminal illness to request medical assistance to die. This pathway is legally and operationally separate from the ACD system.

The critical distinction: you cannot request or pre-authorise voluntary assisted dying through your advance care directive. VAD requires a conscious, informed, and voluntary request made by a person who has decision-making capacity at the time of the request. A substitute decision-maker cannot make a VAD request on your behalf, and no advance instruction — no matter how clearly written — can trigger the VAD process.

The VAD pathway involves:

1. A first request to your coordinating doctor, which can be verbal
2. First and consulting assessments by medical practitioners
3. A written declaration, which is the second request
4. A final request after the written declaration, subject to the minimum 9-day period from the first request (compressible if death or loss of capacity is imminent)
5. Appointment of a contact person, a final review, and an administration permit

If you have a preference for VAD, you can note this in your ACD's values section as a guiding statement — something like, "If I develop a terminal condition and meet the eligibility criteria, I wish to explore voluntary assisted dying." This serves as a signal to your treating team and SDM, but it carries no legal force under the VAD Act. You must initiate the process yourself while you still have capacity.

Where the ACD and VAD interact meaningfully is in palliative care decisions made alongside or instead of VAD. If you choose not to pursue VAD or become ineligible (for example, by losing capacity before completing the process), your ACD's binding refusals govern what happens next.

Palliative Care Preferences

This is where your ACD's instructions matter most. Palliative care — managing pain, symptoms, and quality of life when a condition is no longer curable — is one of the most common clinical scenarios where an ACD activates.

Your ACD can include binding refusals of specific treatments in palliative contexts. For example, you can refuse cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition and hydration, or intensive care admission under specified conditions. If drafted with clinical precision, these instructions are legally binding on treating clinicians.

However, there's a boundary that catches some families off guard: your SDM cannot refuse comfort care or pain relief on your behalf. The Act protects the patient's right to adequate symptom management. Even if your ACD refuses all life-prolonging treatment, the clinical team must continue to provide palliative care to manage pain and distress.

There's also the medical futility question. Clinicians are not legally required to provide treatments they judge to be clinically futile or non-beneficial, even if you or your SDM request them. A doctor who determines CPR would cause more suffering than benefit can write a clinical order to withhold it, documented through the SA Health Resuscitation Alert 7-Step Pathway. This is a clinical decision, not a legal override — but it surprises families who expect every instruction in the ACD to be followed without clinical judgment.

Organ and Tissue Donation

The March 2024 form redesign added an explicit organ and tissue donation section to the ACD. You can record your donation preference in the ACD, but the entry is a preference and does not itself register you as a donor.

This section operates alongside — not instead of — the Australian Organ Donor Register (AODR). Register your decision separately through DonateLife, because the ACD entry alone does not register you as a donor.

In practice, your family will be consulted regardless of what you've documented. Australian organ donation operates on a "family consent" model — even with a registered donor decision, clinical teams will seek your family's agreement before proceeding. Documenting your wishes in your ACD and discussing them with your family ahead of time makes it far more likely your preferences are honoured, because your SDM and next of kin will have clear written evidence of your decision.

One nuance worth noting: if your ACD includes binding refusals of life-sustaining treatment, and you are a potential organ donor, medical interventions may be necessary for organ and tissue donation to take place. Discuss that interaction with your treating team rather than assuming the ACD can require temporary treatment solely for donation.

Funeral and After-Death Wishes

Your ACD does not control funeral arrangements after death. Record burial vs cremation, religious or cultural ceremony requirements, specific funeral directors, and other arrangements in your will and any prepaid funeral plan.

Funeral wishes recorded in a will complement but do not replace arrangements made under a prepaid funeral plan. If you've purchased a prepaid funeral contract, keep its details with your will so your executor can find them.

For families navigating the immediate aftermath of a death, having funeral instructions documented in a will or prepaid plan provides clarity during a time when decision-making is difficult. It also reduces the risk of family disagreements about ceremony arrangements.

Bringing It All Together

The practical takeaway: your ACD is the central document for healthcare decisions, but it works alongside several other legal instruments and systems. VAD is a separate pathway you must initiate yourself. Organ donation works best when your ACD preference is accompanied by AODR registration and a family conversation. Funeral arrangements belong in a will or prepaid plan, not the ACD. And palliative care preferences only carry legal weight when they're drafted with the clinical precision that distinguishes a binding refusal from a non-binding value statement.

The South Australia Advance Directive & Living Will Kit includes pre-drafted treatment refusal scenarios covering palliative care, resuscitation, and end-of-life scenarios, plus an organ donation section and a funeral wishes worksheet — designed so every instruction is clinically specific enough to be binding.

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