Making an Advance Personal Plan

How to make an Advance Personal Plan

The following steps must be completed to make a valid Advance Personal Plan:

1. Fill in the Advance Personal Plan form

Advance Personal Plan form PDF (153.8 KB)
Advance Personal Plan form DOCX (77.9 KB)

2. Have the Advance Personal Plan signed in the presence of an authorised witness
3. Ensure the Advance Personal Plan is accessible when required. It is important to make the plan easy to locate by:

• Registering the Advance Personal Plan with the Public Trustee in the NT.
• Providing copies to the appointed decision maker(s).
• Providing copies to any health care providers including hospitals.
• Sharing the plan with legal representatives, friends, or family.
• Updating details on My Health Record.

Assistance and advice is available from:

• Doctors or other treating care professionals, who can provide medical advice.
• The National Advance Care Planning Support Service.
• Legal professionals or services.
• The Public Guardian and Trustee.

Find out more about the Public Guardian and Trustee’s Advance Personal Plan Assistance Service

Signing an Advance Personal Plan

An Advance Personal Plan must be signed by the adult making it, with an authorised witness present.

If a person has capacity to make an Advance Personal Plan but cannot sign it, they can ask another person to sign for them. A representative can only sign the plan on behalf of a person when the person is physically unable to sign it. This could be due to injury, arthritis or other mobility issues.

If a representative signs on behalf of the person, the person must be present with them.

The representative:

• must be at least 18 years old, and
• must not be a decision maker for the adult in the plan
• Any of the following can be a witness:
  • Justice of the Peace or Commissioner for Oaths
  • police officer
  • legal practitioner
  • health professional
  • accountant
  • chief executive officer of a local government authority
  • social worker
  • Northern Territory school principal.

Information for witnesses

An Advance Personal Plan must be signed by the person creating it (or by someone acting on their behalf) in front of an authorised witness.

The witness must confirm in the Advance Personal Plan that:

• the person is who they say they are
• the person is at least 18 years old
• the person understands what the Advance Personal Plan means
• the person is making the plan willingly, without pressure or influence.

The plan was signed by the adult, or their representative as required in the witness's presence.

What can be in an Advance Personal Plan

Everyone's Advance Personal Plan will be different and will reflect their views and wishes for their future care.

An Advance Personal Plan can include one, some or all of the following.

An Advance Care Statement

A statement to guide others in making decisions aligned with the person's views, wishes and beliefs.

Advance Consent Decisions

These are specific care decisions that will be treated as consent for future medical treatment.

Appointment of a decision maker

A trusted individual given legal authority to make decisions on the person's behalf.

Writing Advance Care Statements

Advance Care Statements describe the person's views, wishes and beliefs for future decision makers to follow. Unlike Advance Care Decisions, these statements are not legally binding. They are meant to support decision-making and can relate to:

• health care needs
• lifestyle choices
  • living arrangements
  • diet
  • entertainment
  • clothing
• financial matters, like managing property and other assets.

These statements are meant to reflect what is important to the person. They help decision maker's act in line with the person's values.

Wishes and preferences to consider:

• preferred living arrangements
• important connections with family, friends and community
• involvement in religious or social groups
• enjoyable activities or past times.

Views and beliefs to include:

• preferences regarding pain management
• attitudes toward longevity and quality of life
• the importance of dignity and independence.

Examples of Advance Care Statements:

• "I want to receive care at home as much as possible, rather than in a hospital or nursing home."
• "I wish to maintain connection with my church."
• "If I cannot manage my personal hygiene, I prefer to have professional care rather than family assistance."

Making Advance Consent Decisions

An Advance Personal Plan can include instructions on future specific health decisions. These are referred to as 'Advance Consent Decisions'. These decisions are legally binding so must be followed by health care professionals. They do not need consent from appointed decision makers.

Advance Consent Decisions can only be about health care (including mental health). They can cover:

• Specific treatments - approving or declining things like surgery or chemotherapy.
• End-of-life decisions - choosing to receive cardiopulmonary resuscitation (CPR) or other life‑saving measures.
• Refusing care - specifying treatments a person does not want.

Examples of Advance Consent Decisions include:

• "If I develop an illness from which there is no hope of recovery, I do not consent to life-sustaining measures such as cardiopulmonary resuscitation (CPR), assisted ventilation, artificial feeding or hydration."
• "I consent to artificial feeding and hydration if it is required to recover from a reversible condition."
• "I do not want to be given a blood transfusion under any circumstances."
• "If I have a terminal illness and am going to die soon, I do not want to be given treatment just to keep me alive for a little bit longer. Just keep me pain free."

Appointing a decision maker

One of the most important areas in an Advance Personal Plan is choosing a decision maker. This is the person who will make decisions on behalf of the individual if they lose the ability to make decisions for themselves.

The decision maker should be someone the person trusts, understands their wishes, respects their values, and is capable of making decisions in their best interest.

Choosing the right person can provide peace of mind that the person will be supported and well looked after if they become unable to make their own decisions.

However, there have been situations where the power given to a decision maker through an Advance Personal Plan has been misused. This highlights the importance of careful planning and open discussion with the chosen decision maker.

When selecting someone for this role, it is essential that they:

• are willing to listen to, and act on, the person's wishes rather than their own
• are trustworthy
• have the time and skills required to carry out the role
• are willing to take on the role with all its responsibilities
• can communicate well and consult with others when needed
• understand and respect the person's culture and community connections
• are capable of managing property and finances (if these responsibilities are being assigned to them).

A decision maker can be:

• a spouse or partner
• a relative or friend (if under 18 when appointed, they cannot make decisions until they turn 18)
• the Public Guardian (for personal matters)
• the Public Trustee (for financial matters).

Decision makers can be assigned specific roles, for example, one person can manage financial matters while another handles all other matters. Decisions makers can also be appointed to make decisions together. Limitations can also be placed on their authority.

Where there are any questions about a person's ability to be a decision maker, it is recommended that they are not appointed and legal advice is sought.

Advance Care Planning Australia provides additional resources and support.

The Public Guardian and Public Trustee appointed as decision makers

The Public Guardian and Public Trustee can also be appointed as a decision maker in an Advance Personal Plan.

If the Public Guardian or Public Trustee is appointed they must follow the same rules as any other decision maker. They can only make decisions when the person has not got the ability to make their own.

When the Public Guardian and Trustee needs to make a decision, they will talk with the person. They will also talk to their family, friends, and healthcare providers. This will help make sure decisions made on the person's behalf take into account the person's wishes and preferences.

If someone registers their plan with the Public Guardian and Trustee as future decision makers, staff may contact them to talk about:

• their wishes and preferences
• their beliefs
• information in the plan.

This ensures future decisions can be as close as possible to what the person would have wanted.

Enduring Powers of Attorney

In 2014, Advance Personal Plans replaced Enduring Powers of Attorney in the Northern Territory. This means no new Enduring Power of Attorney documents can be created. However, any documents created before 2014 can be used.

Existing Enduring Powers of Attorney should be reviewed. This ensures the information is current. Where changes are needed, an Advance Personal Plan should be completed.

Using an interstate Power of Attorney in the Northern Territory

Most interstate Powers of Attorney can be used in the Northern Territory. However, people moving to the Northern Territory permanently are recommended to make an Advanced Personal Plan.

Visit Advance Care Planning Australia for more information.