Advance Care Directive Template

1. APPOINTMENT OF SUBSTITUTE DECISION-MAKER. I appoint Sarah J. Mitchell (my Sister), telephone: +61 2 9876 5432, as my substitute decision-maker to make healthcare decisions on my behalf if I am unable to make or communicate decisions myself. My decision-maker must act consistently with the wishes expressed in this directive and, where my wishes are unclear, must act in my best interests. If my primary decision-maker is unable or unwilling to act, I appoint Patrick D. O'Brien (telephone: +61 412 345 678) as my alternate.

2. LIFE-SUSTAINING TREATMENT. I direct that life-sustaining treatments be provided only where there is a reasonable prospect of recovery to a quality of life I would consider acceptable. If my treating medical team determines that my condition is terminal with no reasonable prospect of recovery, or that I am in a persistent vegetative state, I direct that life-sustaining measures be withheld or withdrawn, and that I receive comfort care only.

3. SPECIFIC TREATMENT PREFERENCES.

Cardiopulmonary Resuscitation (CPR): I do not consent to cardiopulmonary resuscitation (CPR). I direct that a Not for Resuscitation (NFR) order be placed on my medical records.

Mechanical Ventilation: I consent to a time-limited trial of mechanical ventilation. If there is no meaningful improvement within a period determined by my treating team, I direct that ventilation be withdrawn.

Artificial Nutrition and Hydration: I consent to short-term artificial nutrition and hydration only. If my condition does not improve meaningfully, I direct that artificial nutrition be withdrawn.

4. PAIN MANAGEMENT AND PALLIATIVE CARE. I direct that I receive maximum available pain relief and palliative medication to keep me comfortable, even if such medication may have the secondary effect of hastening death. Comfort and freedom from pain are my primary concern.

5. ADDITIONAL HEALTHCARE INSTRUCTIONS. I wish to remain at home or in a hospice setting for end-of-life care where possible. Religious and cultural considerations: Catholic faith; I welcome pastoral visits and last rites.

6. ORGAN AND TISSUE DONATION. I wish to donate all viable organs and tissues upon my death for transplantation, medical research, or education. I authorise my substitute decision-maker and appropriate medical personnel to facilitate this in accordance with state human tissue legislation.

7. GENERAL PROVISIONS.

Capacity: I make this directive while I have full mental capacity to do so and understand the nature and effect of each direction.

Revocation: I may revoke or amend this directive at any time while I have decision-making capacity. Any revocation must be in writing and signed in the presence of a witness.

Copies: A photocopy of this directive has the same force and effect as the original. I direct that copies be given to my substitute decision-maker, my general practitioner, and any hospital or aged care facility where I receive treatment.

Governing Law: This directive is made under and shall be interpreted in accordance with the Medical Treatment Planning and Decisions Act 2016 (Vic) and any applicable Commonwealth legislation.

I, James T. O'Brien, of 45 George Street, Sydney NSW 2000, in the State of VIC, being of sound mind and understanding, make this Advance Care Directive to express my wishes regarding healthcare decisions in the event that I become unable to make or communicate such decisions for myself. This directive is made in accordance with the Medical Treatment Planning and Decisions Act 2016 (Vic).

Two adult witnesses are required in most Australian states. At least one witness must not be a relative, carer, or a person who may benefit from the declarant's estate. Requirements vary — refer to the applicable state legislation.