Advance Care Planning for Aged Care in Western Australia

Facilities Expect These Documents — Most Families Don't Have Them

When a parent or partner moves into residential aged care in Western Australia, the facility's intake team will ask for advance care planning documents. Specifically, they'll want to know whether the resident has an Advance Health Directive (AHD), an Enduring Power of Guardianship (EPG), and an Enduring Power of Attorney (EPA). Most families arrive without any of them.

That gap creates immediate pressure. The aged care facility needs to know who can consent to medical treatment, who can make decisions about daily care, and where the legal authority sits if the resident's health deteriorates. Without the right documents, clinical staff fall back on WA's statutory hierarchy of treatment decision-makers — a rigid sequence that may not reflect the resident's actual wishes or family dynamics.

What Aged Care Facilities Need From You

Advance Health Directive (AHD)

The AHD records the resident's specific treatment preferences under Part 9B of the Guardianship and Administration Act 1990. Aged care facilities in WA use the AHD to guide clinical decisions when the resident can't communicate — particularly around:

• Hospitalisation: Whether the resident should be transferred to hospital for acute treatment or remain at the facility with palliative support
• Resuscitation: Whether CPR and mechanical ventilation should be attempted
• Antibiotics and IV fluids: Whether to treat infections aggressively or focus on comfort care
• Artificial nutrition: Whether tube feeding is acceptable if swallowing deteriorates

Facilities will scan and upload the AHD to the resident's clinical file. They'll also check My Health Record for a digital copy. If the AHD is older than 10 years, clinical staff have the legal right to "read down" its authority — assessing whether the treatment decisions still reflect the maker's likely wishes given changes in medical technology and the person's condition.

Enduring Power of Guardianship (EPG)

The EPG tells the facility who can make personal and lifestyle decisions for the resident. This includes consenting to changes in room allocation, adjusting care plans, approving participation in activities, and making medical decisions not covered by the AHD.

Without an EPG, the facility must navigate the statutory hierarchy each time a decision is needed. This slows everything down and can create friction between family members who each believe they have authority.

Enduring Power of Attorney (EPA)

The EPA covers financial matters — paying the facility's fees, managing the resident's bank accounts, and handling any property transactions. Aged care in WA involves significant costs, and the resident's accommodation payment (often hundreds of thousands of dollars as a Refundable Accommodation Deposit) needs someone with legal authority to manage it.

If the resident owns real property, the EPA must be registered with Landgate before any sale or transfer can proceed.

The Hospital Admission Scenario

Aged care residents frequently move between their facility and hospital — for falls, infections, cardiac events, or planned procedures. Each hospital admission triggers a fresh clinical assessment and a new Goals of Patient Care (GoPC) discussion.

The GoPC is a non-statutory clinical tool used across WA public hospitals and health services (including WA Country Health Service facilities in regional areas). It establishes the "ceiling of care" for that specific admission — what interventions are appropriate, whether ICU admission should be attempted, and what level of resuscitation effort should be made.

Here's how your advance care documents interact with the hospital process:

1. Paramedics or transport staff work from any immediate clinical orders available during transfer
2. The admitting hospital team reviews any existing AHD and contacts the enduring guardian or next-of-kin
3. A GoPC discussion is initiated with the patient (if capable) or their substitute decision-maker
4. The GoPC form is completed as a clinical order for the current admission period
5. If a valid AHD exists with specific treatment decisions, those decisions override the family's preferences — the GoPC must be consistent with the AHD

For families, the key point is this: if your parent has a clear AHD and an appointed enduring guardian, the hospital process is smoother. The clinical team knows what's been consented to, who to call, and what treatment boundaries exist. Without those documents, every decision becomes a discussion — often a difficult one, at 2am, with a family member who doesn't know what Mum would have wanted.

Palliative Care and End-of-Life Planning in Aged Care

Many aged care residents in WA eventually transition to a palliative care pathway — either within their facility or at a specialist palliative care unit. This transition raises specific advance care planning considerations.

Residential Goals of Care (RGoC): Similar to the hospital GoPC, but designed for the residential setting. The facility's clinical team completes the RGoC in consultation with the resident or their decision-maker. It covers treatment escalation, transfer-to-hospital preferences, and comfort measures.

Palliative care preferences in the AHD: If your AHD specifies comfort care or palliative care as your preferred approach, the aged care facility and any treating hospital must respect that. Be specific about what comfort care means to you — pain management, anti-anxiety medication, hydration, presence of family — rather than relying on the phrase alone.

Voluntary Assisted Dying (VAD): Under the Voluntary Assisted Dying Act 2019, VAD cannot be requested through an AHD or by an enduring guardian. The person must maintain decision-making capacity throughout the entire VAD assessment and administration process. For aged care residents with progressive cognitive decline, access therefore depends on retaining active decision-making capacity throughout the VAD process. More detail in our VAD and advance directives post.

Timing: Before Admission, Not After

The ideal time to complete advance care planning documents is before the aged care admission process begins. Once someone is in crisis — a sudden decline, a hospital admission, an urgent aged care placement — the pressure to make decisions quickly can compromise the quality of the planning.

If your family member still has capacity but is entering aged care:

1. Book a GP appointment specifically for advance care planning. The GP can assess capacity, discuss treatment preferences in clinical terms, and ensure the AHD's treatment decisions are realistic.
2. Complete the AHD and EPG with proper witnessing (two independent adult witnesses, at least one authorised under the Oaths, Affidavits and Statutory Declarations Act 2005).
3. Upload to My Health Record — this ensures every WA hospital can access the documents digitally, even if the paper originals are at the facility.
4. Provide certified copies to the aged care facility during intake, to the GP, and to the appointed enduring guardian.
5. Review the documents every two to five years, or whenever there's a significant change in health status or personal circumstances.

Regional WA: Additional Considerations

For families in the Wheatbelt, Goldfields-Esperance, Kimberley, or other regional and remote areas, advance care planning carries extra urgency. Regional aged care facilities may not have the same clinical resources as metropolitan Perth facilities, and emergency hospital transfers can involve long distances by road or air.

Having a clear AHD with specific treatment decisions reduces the burden on regional health staff who may be making time-critical decisions during a medical transport. The WA Country Health Service (WACHS) recognises AHDs and will check My Health Record during emergency presentations.

Finding authorised witnesses in small regional communities can be challenging. Currently registered doctors, nurses, pharmacists, lawyers, police officers, and JPs all qualify. Our post on witnessing requirements has the full list.

Getting Started

The Western Australia Advance Directive & Living Will Kit includes everything you need to prepare advance care planning documents before an aged care admission: the treatment decision worksheets, GP consultation preparation guides, signing and witnessing checklists, and a step-by-step My Health Record upload walkthrough. It also covers the Enduring Power of Guardianship process, so your appointed decision-maker has proper legal authority from day one.

Getting these documents done before the aged care transition removes one major source of stress from an already difficult period.

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