CASE STUDY: Another step in the right direction

Case study


On reflection, she thinks this is probably a habit that she inherited from her father. “From a legal point of view, my dad always had a Will to cover our family and the business. He also had documentation in place to make sure medical and financial power of attorney would pass to me and my older brother, if it ever came to that.”

With these safeguards in place, Maria felt confident that her family had “covered all bases” in relation to end-of-life matters. Consequently, she had no immediate reason to think much further about the prospect of making medical decisions on behalf of her parents.

However, this changed in 2015 when Maria’s mother, Rosa, was diagnosed with Alzheimer’s disease, and her father then passed away shortly after from a heart condition. In line with the wishes of both parents, Maria took on the role of primary carer for Rosa, and became a joint power of attorney.

At the time, Maria remembers thinking: “We’ve got the Will and power of attorney in place. That’s all we need.” She had never heard of advance care planning until her mother’s general practitioner (GP) brought it up during a routine medical appointment in early 2016.

"Medical power of attorney is a really good start, but it doesn’t cover everything. There can be gaps when it comes to treatment decisions."

Maria says: “The doctor wrote down ‘Advance Care Directives South Australia’ on a piece of paper and explained the basics to us. As it turns out, medical power of attorney is a really good start, but it doesn’t cover everything. There can be gaps when it comes to making decisions about medical treatment.”

As the GP explained to them, medical power of attorney would allow Maria and her brother to make decisions on Rosa’s behalf. An Advance Care Directive† would go one step further by taking Rosa’s values, beliefs and preferences into account. In short, this could help to provide additional guidance on future treatment decisions – not only for Maria and her family, but also for the healthcare professionals involved in Rosa’s care.

For Maria, this opportunity to add an extra layer of protection, while also respecting her mother’s wishes in the process, seemed like a “no-brainer”. Keen to find out more, Maria went online and did some further research as soon as she got home from Rosa’s medical appointment.

As Maria explains: “I’m always mindful that things can go wrong, so I decided to get on top of the planning straight away. It was really easy to do, and the timing was ideal because mum was mentally alert, so we were able to have a good discussion with her about different future care scenarios.”

In South Australia, an Advance Care Directive can be completed online, so Maria sat down with her mother and brother and they worked through it together in a single sitting. Maria says: “I had the laptop and we clicked through the online fields and examples one by one. Mum knew it was all to look after her, so she was more than happy to have that extra security.”

On completing the online process, Maria arranged for Rosa to review and sign the forms in the presence of an independent witness – in this case, a Justice of the Peace (JP). As substitute decision-makers, Maria and her brother also signed the forms. To formally lodge the documentation, Maria submitted the signed forms by email while also retaining certified copies for her own records.

"It was really easy to do, and the timing was ideal because mum was mentally alert, so we were able to have a good discussion with her about different future care scenarios."

In fact, Maria found the process so straightforward that she thought they might have missed a step. She says: “I actually contacted Advance Care Directives South Australia to check if we had to take any further action because it seemed so simple – almost too simple! They just reminded me to share copies with those involved in mum’s care.”

A year later, Rosa moved into a retirement village, where she has remained in good health. As a result, the family hasn’t had to update or revisit the Advance Care Directive, other than to advise the retirement village and Rosa’s healthcare professionals that it exists.

On a day-to-day basis, nothing has really changed for Maria, but she is glad to have been introduced to advance care planning for the peace of mind it brings her. In summing up her experience, Maria says: “It only took an hour of my time and it was very simple. Now I really do feel like we have covered all bases.”


Advance care planning:

  • is essential to person-centred care
  • promotes care that is consistent with a person’s goals, values, beliefs and preferences
  • prepares people and their substitute decision-makers for making healthcare decisions
  • improves outcomes for people, their family and carers, health, aged and community care workers, and the health system
  • is part of routine care, and the person’s healthcare journey
  • is an ongoing process
  • may be initiated or completed by the person themselves or by health, aged and community care workers.

* Names and personal details have been changed for privacy reasons

Advance care planning documents can have different names depending on the state or territory. Find forms for your location >

Read other case studies

  • Case study

    The things that matter

    Advance Care Planning Australia

    Community educations sessions and facilitated discussions guided by volunteers is a way to prompt individuals to think about advance care planning.
  • Case study

    The key matters

    Advance Care Planning Australia

    The process of advance care planning can help you work through important issues.
  • Case study

    The state of things

    Advance Care Planning Australia

    Australia doesn't have a national law covering advance care planning, so it is help to understand the requirements for your state or territory.