[{"id":"1e3c8fa2-d8e9-44c9-a388-dd76e6efae4d","order":1,"text":"ADVANCE CARE DIRECTIVE","fontSize":"22","textAlign":"center","bold":true,"underline":false,"marginBottom":"0","cflou":false,"active":true},{"id":"93588d02-102c-47f6-aa88-ebd5d4eb155a","order":2,"text":"AND APPOINTMENT OF MEDICAL TREATMENT DECISION MAKER","fontSize":"16","textAlign":"center","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e2797f4b-4e41-43a3-b930-27d04c2df029","order":3,"text":"Made under the Medical Treatment Planning and Decisions Act 2016 (Vic)","fontSize":"12","textAlign":"center","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"88ef6b0d-f626-470e-be1d-261f531245ef","order":4,"text":"THIS ADVANCE CARE DIRECTIVE is made by:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"eef2b811-48a8-43da-81a6-d231e8631c7d","order":5,"text":"[Full name], born on [Date of birth], of [Residential address] (in this document referred to as "I", "me" or "the person").","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"b53212fb-a4b1-4ffe-8997-e3bcbe0daed4","order":6,"text":"1. INTERPRETATION AND STATUS OF THIS DOCUMENT","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S01"},{"id":"5f3ddc68-a2bf-41e4-9013-36d341bf852b","order":7,"text":"This document is an advance care directive within the meaning of the Medical Treatment Planning and Decisions Act 2016 (Vic) (the "Act"). It records my binding instructions and my values and preferences concerning medical treatment, and it appoints a medical treatment decision maker to make medical treatment decisions on my behalf.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"cf5a7735-2244-4321-af50-88801d7eca79","order":8,"text":"In this document: "medical treatment" has the meaning given in the Act and includes treatment provided by all registered health practitioners; an "instructional directive" is an express statement in which I consent to, or refuse, the commencement or continuation of medical treatment; and a "values directive" is a statement of my preferences and values in relation to my medical treatment.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"62ef9d6e-0588-4bc2-a243-a6c0bd067973","order":9,"text":"This document operates only if and for so long as I do not have decision-making capacity in relation to a medical treatment decision. While I have decision-making capacity, I make my own medical treatment decisions and this document has no operative effect.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"cf1cf027-ab63-43a1-b451-715ca4df5208","order":10,"text":"An instructional directive contained in this document takes effect as if I had consented to, or refused, the medical treatment at the time the decision is required, and is binding on health practitioners. A values directive is to be given effect by my medical treatment decision maker and by health practitioners as a guide to any medical treatment decision made on my behalf.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8eabb0e9-ac0a-47c7-a802-4923e4f909fe","order":11,"text":"2. DECLARATION OF THE PERSON MAKING THIS DOCUMENT","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S02"},{"id":"dd1b7978-b34f-405c-9de7-b2b734a8895c","order":12,"text":"I declare that, at the time of making this document, I am at least 18 years of age and I have decision-making capacity in relation to each statement set out in this document.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"dc68b1e5-e2d1-4cb8-a982-a73a3b6b85dd","order":13,"text":"I understand the nature and effect of each statement in this document. I understand that I am giving instructions about my future medical treatment, and that an instructional directive refusing treatment must be complied with even if it results in my death.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"e1a3302c-34f9-4c93-a8bd-853b4a7492f6","order":14,"text":"I am making this document freely and voluntarily, and not because of any inducement, pressure or undue influence by any other person.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"cd288e74-b38c-4e71-a40f-67cdcdf46f95","order":15,"text":"I understand that I may amend or revoke this document at any time while I have decision-making capacity to do so.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f82a9fa8-494c-4c88-9445-aa96ff696f42","order":16,"text":"3. VALUES DIRECTIVE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}],"sectionNum":"S03"},{"id":"901cd062-7994-4e4b-b51b-f2a64239fdcd","order":17,"text":"This section records my values and preferences to guide any medical treatment decision made on my behalf when I do not have decision-making capacity. I ask that my medical treatment decision maker and my health practitioners give effect to the following.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"822cbcc5-2630-4630-a361-6ed58007084b","order":18,"text":"What living well means to me, and the outcomes I would or would not find acceptable:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"b5c0ed50-5ecb-4d23-8bd9-409def85405e","order":19,"text":"[Describe what quality of life and living well mean to you]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"8e6d319e-4a04-4be3-a9e5-4dc0e13d0565","order":20,"text":"My beliefs, values and matters that are important to me (including any cultural, religious or spiritual considerations):","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"a3906aff-23ad-44cb-8342-da44bf357a60","order":21,"text":"[Describe the beliefs and values that should guide decisions]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"1165149a-6a2e-4344-9b6d-f3929480e523","order":22,"text":"My preferences about where I would like to be cared for, and any other wishes concerning my care:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"0029b801-2ed9-4f15-8fe1-6692a765d195","order":23,"text":"[Describe your preferences about place and manner of care]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"5f22aa3b-db64-4b71-9610-fb3d676fc3fc","order":24,"text":"I ask that, wherever reasonably possible, I be afforded comfort and dignity, that my pain and distressing symptoms be relieved, and that palliative care be provided to me in accordance with good clinical practice.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"bc40ea46-b098-4103-9b6f-5558be39e2c6","order":25,"text":"If I am pregnant at a time when a medical treatment decision must be made for me, I ask that the following preference be taken into account:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"4fb9bdbd-ff29-43bf-b1b2-f8f655310216","order":26,"text":"[Your preference if you are pregnant, or write Not applicable].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4b533065-d60d-40bf-8b72-56d19811c889","value":"Yes","type":"add","operator":"="}]},{"id":"e7208542-2dce-4b9f-b461-058f036e6138","order":27,"text":"4. INSTRUCTIONAL DIRECTIVE","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}],"sectionNum":"S04"},{"id":"5f296d73-b010-405a-bf3a-a35d0d52ec63","order":28,"text":"This section contains my binding instructions consenting to, or refusing, particular medical treatment. These instructions take effect only when I do not have decision-making capacity. Where I have given a specific direction below, that direction is to be followed. Where I have given no specific direction in relation to a treatment, the decision is to be made by my medical treatment decision maker, guided by my values directive.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"97793675-2aeb-4bd9-bffc-546b1c89c7cb","order":29,"text":"Cardiopulmonary resuscitation (CPR), being attempts to restart my heart or breathing — [my direction].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"255af7db-6444-4c4d-86e0-53bd34f7f7eb","order":30,"text":"Assisted ventilation or intubation to support or replace my breathing — [my direction].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"82edb704-f928-4b42-83a6-2ecdae6d0b7b","order":31,"text":"Artificial nutrition and hydration provided by tube or intravenously — [my direction].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"5beea6f0-86c9-4667-9d13-6ab34fc1e510","order":32,"text":"Renal dialysis to replace kidney function — [my direction].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"1163afcf-1281-4515-af22-508b8d47d250","order":33,"text":"Blood transfusion and administration of blood products — [my direction].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"66e6216e-5720-448e-9497-436ec937fd09","order":34,"text":"Administration of antibiotics or antiviral medication to treat life-threatening infection — [my direction].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"566f16b3-fce8-4dfe-8377-09bdbd1bb890","order":35,"text":"Major surgery undertaken to prolong my life — [my direction].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"40d8000b-b1c5-4429-a21f-0bdbf117885e","order":36,"text":"Any additional instructions consenting to or refusing medical treatment:","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"d18ccb01-b741-4904-bafb-1e5895eb35fd","order":37,"text":"[Any further specific instructions, or write None]","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"d1204851-5ff1-4300-8b2f-7066233f0417","order":38,"text":"I understand that a refusal of treatment set out above is binding and must be complied with, and that a health practitioner is not required to act in a manner that is unlawful, that is inconsistent with proper professional standards, or that would require the provision of treatment that is not clinically indicated.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"19025f40-7e7b-46b5-bc45-97217a1b22d4","value":"Yes","type":"add","operator":"="}]},{"id":"844b15ae-f410-42a3-85f4-feec5611c583","order":39,"text":"5. DECISION-MAKING STANDARD, CONSULTATION AND SPECIAL PROCEDURES","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S05"},{"id":"1f1561f5-9781-40e2-856f-c0864357d081","order":40,"text":"Decision-making standard. I direct that any medical treatment decision made on my behalf be the decision that my medical treatment decision maker reasonably believes I would have made in the circumstances, having regard to my instructional directive, my values directive, and any other preferences and values I have expressed. In doing so, my medical treatment decision maker must act in good faith and with due diligence.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8f56335d-bbbb-48f0-9783-f0c92dc38eee","order":41,"text":"Persons to be consulted. In addition to any person the Act requires or my medical treatment decision maker considers appropriate, I ask that the following person or persons be consulted before a significant medical treatment decision is made on my behalf, so far as they are reasonably available:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"8","cflou":false,"active":true,"displayConditions":[{"field":"7150984c-245b-4df9-a9ba-5306186482af","value":"Yes","type":"add","operator":"="}]},{"id":"e4aaf1fe-de88-49f2-8d75-0284be6febdc","order":42,"text":"[Names and, if relevant, contact details of persons to be consulted].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"7150984c-245b-4df9-a9ba-5306186482af","value":"Yes","type":"add","operator":"="}]},{"id":"970c43f0-a3ea-4eee-8fed-744b12eb128f","order":43,"text":"Special medical procedures. I understand that certain special medical procedures — namely the termination of pregnancy, sterilisation and the removal of tissue for donation to another person while I am living — are regulated separately under the Guardianship and Administration Act 2019 (Vic) and cannot be authorised by an instructional directive or by my medical treatment decision maker alone. Any wishes I have expressed in this document about such procedures are to be treated as a statement of my values and preferences only.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"b4eec3cc-fc39-4999-aeb2-8fbec761c00d","order":44,"text":"Medical research. If, while I do not have decision-making capacity, it is proposed that I take part in a medical research procedure, I direct that my medical treatment decision maker decide the matter in accordance with the decision-making standard set out above, and only where participation is not contrary to my known preferences and values.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"f24db9c0-2100-444c-b626-5567e6c13e2a","order":45,"text":"Voluntary assisted dying. I understand that a decision in relation to voluntary assisted dying is a decision for me alone while I have decision-making capacity, that it cannot be made by my medical treatment decision maker on my behalf, and that nothing in this document authorises or requires any person to make such a decision for me.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"ba635dd5-7ba4-4807-9f26-be4847579e50","order":46,"text":"6. APPOINTMENT OF MEDICAL TREATMENT DECISION MAKER","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S06"},{"id":"d28a924a-261f-4e0a-bdfc-18509d001c02","order":47,"text":"I appoint the following person to be my medical treatment decision maker under the Act, to make medical treatment decisions on my behalf when I do not have decision-making capacity:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"01d2455f-1a34-48b8-9e1f-0b7ad31869cf","order":48,"text":"[Full name of decision maker], of [Address], telephone [Contact number], whose relationship to me is [Relationship].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"9930c0fe-6aa2-4f44-af44-1afbfc21ba2e","order":49,"text":"If my first-appointed medical treatment decision maker is not available, is unwilling or is unable to act, I appoint as my alternate medical treatment decision maker:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"6c879d8a-8229-41a5-95f6-0eb608bf68f0","value":"1","type":"add","operator":"="},{"field":"6c879d8a-8229-41a5-95f6-0eb608bf68f0","value":"2","type":"add","operator":"="}]},{"id":"2947b7ac-108d-4ae7-a106-b9d3a54072fc","order":50,"text":"[Full name of first alternate], of [Address], telephone [Contact number], whose relationship to me is [Relationship].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"6c879d8a-8229-41a5-95f6-0eb608bf68f0","value":"1","type":"add","operator":"="},{"field":"6c879d8a-8229-41a5-95f6-0eb608bf68f0","value":"2","type":"add","operator":"="}]},{"id":"b902d3aa-35ef-4c81-9e63-77de5de39295","order":51,"text":"If neither of the above is available, is unwilling or is unable to act, I appoint as my second alternate medical treatment decision maker:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"6c879d8a-8229-41a5-95f6-0eb608bf68f0","value":"2","type":"add","operator":"="}]},{"id":"5540098a-3522-45c8-af44-a9faece3a2e4","order":52,"text":"[Full name of second alternate], of [Address], telephone [Contact number], whose relationship to me is [Relationship].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"6c879d8a-8229-41a5-95f6-0eb608bf68f0","value":"2","type":"add","operator":"="}]},{"id":"8793037a-db50-4273-bc30-c7fe3f3411da","order":53,"text":"Only one medical treatment decision maker may act at any one time, and each alternate may act only if every person appointed before them is unavailable, unwilling or unable to act. I direct that my medical treatment decision maker make each decision that they reasonably believe is the decision I would have made, having regard to my values directive and to any other relevant preferences and values I have expressed.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"9b18e49b-c0dc-4e57-b487-91a77ce7a8fb","order":54,"text":"I understand that my medical treatment decision maker has authority to make medical treatment decisions on my behalf but cannot override an instructional directive given by me, and cannot make a decision about voluntary assisted dying on my behalf.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"453202ad-7877-4a10-b978-5590a4f12285","order":55,"text":"Eligibility. Each person appointed above is an adult, is reasonably available, and is willing and able to perform the role. I confirm that I have not appointed as my medical treatment decision maker any person who is, in a professional capacity, responsible for my health care or a provider of accommodation services to me.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"48628594-f302-4ce0-96cd-1102edad916a","order":56,"text":"Duties of my medical treatment decision maker. When acting, my medical treatment decision maker must give effect to my instructional directive, apply the decision-making standard set out above, consult the persons I have identified so far as they are reasonably available, and act in good faith and with due diligence.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"9e2fd2dc-51cf-4ee2-a2b6-27047a9ce6e5","order":57,"text":"7. APPOINTMENT OF SUPPORT PERSON","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}],"sectionNum":"S07"},{"id":"d352e909-026d-49c4-b89a-86730a6ebf15","order":58,"text":"I appoint the following person to be my support person under the Act, to support me to make, communicate and give effect to my own medical treatment decisions, to represent my interests, and to access and collect health and personal information relevant to my medical treatment:","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"313a2a51-519c-4bf9-bf3d-b00bbd7b66e8","order":59,"text":"[Full name of support person], of [Address], telephone [Contact number], whose relationship to me is [Relationship].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"9709af39-308b-47f7-8718-47a46dd8e91a","order":60,"text":"I understand that a support person does not make medical treatment decisions on my behalf, and that only one person may hold the role of support person at any one time. This appointment revokes any previous appointment of a support person made by me.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"7c9d7d49-1c5c-470d-a09a-689e845272ba","order":61,"text":"8. ORGAN AND TISSUE DONATION AFTER DEATH","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S08"},{"id":"4fe1c256-c8cb-4d63-8468-b049a0c7991c","order":62,"text":"In relation to the donation of my organs and tissue for transplantation or other therapeutic, medical or scientific purposes after my death, I record the following wish: [my wish regarding donation].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"2725f7ce-9b47-4b0a-bd19-1d02a4ed7ac8","order":63,"text":"I understand that this statement is an expression of my wishes to assist those who will be responsible for decisions after my death, and that donation remains subject to the law in force at the relevant time and to clinical suitability.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"13628791-35b1-4c14-a28e-76545c9ffa53","order":64,"text":"9. GENERAL PROVISIONS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S09"},{"id":"1019ee1c-be61-4c00-a414-9e962786dfc1","order":65,"text":"Palliative care and pain relief. Nothing in this document prevents the administration to me of reasonable palliative care, including the relief of pain and suffering, in accordance with good clinical practice.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"da360e71-9bc0-4f45-9ef3-58b151c7fa14","order":66,"text":"Emergency treatment. I understand that, in an emergency, a health practitioner may lawfully administer treatment to me without consent where it is not practicable to determine whether an instructional directive or a medical treatment decision maker applies, and that such treatment must nonetheless have regard to any known instructional directive of mine.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"c5b33d73-7718-4235-b6ee-d25b87d9fe1f","order":67,"text":"Severability. If any statement or part of this document is found to be invalid or unenforceable, that finding does not affect the validity or enforceability of the remaining statements, which continue in full force and effect.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"d49391d6-887d-4e77-8a5d-16e3680f1c39","order":68,"text":"Copies. A copy of this document, including an electronic or photographic copy, is to be treated as having the same effect as the original.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"de81012e-798f-4f78-a7c0-06ac5975b133","order":69,"text":"Governing law. This document is made under, and is to be interpreted in accordance with, the law of the State of Victoria, Australia.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"705bbcb3-d7d4-4925-bf10-22eb74cac5b8","order":70,"text":"Other appointments. This document does not affect any enduring power of attorney I have made for financial or personal matters, except to the extent that such an instrument purports to authorise a person to make medical treatment decisions for me, in which case this document prevails.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"387f4c77-b6aa-4a2d-9e9f-0c2b19279347","order":71,"text":"Review by VCAT. I understand that the Victorian Civil and Administrative Tribunal may, on application, make orders in relation to this document, including as to its validity or the suitability of a person appointed under it.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"05c6117f-bfbe-4a08-8c63-53ae9454077f","order":72,"text":"Custody and access. I intend that copies of this document be given to my medical treatment decision maker, my support person (if any), my general practitioner and any hospital or health service treating me, and that it may be uploaded to My Health Record so that it is available to those responsible for my care.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"1d5627c4-1af7-45b7-aa3e-5e4a0fb93ef3","order":73,"text":"Effect of most recent document. Where I have made more than one advance care directive or appointment, the most recent valid document prevails to the extent of any inconsistency.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"906a1c27-1d9f-430e-bbec-1121a9452cc7","order":74,"text":"10. REVOCATION OF PREVIOUS INSTRUMENTS","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S10"},{"id":"db719e5c-3ead-4fdc-b6c5-bbe1227b1b69","order":75,"text":"I revoke any advance care directive and any appointment of a medical treatment decision maker, medical enduring power of attorney, refusal of treatment certificate or similar instrument previously made by me, to the extent that it is inconsistent with this document.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"aca6a62e-09b1-42a7-8f10-562657afc278","order":76,"text":"11. SIGNING AND WITNESSING","fontSize":"16","textAlign":"left","bold":true,"underline":false,"marginBottom":"10","cflou":false,"active":true,"marginTop":"20","sectionNum":"S11"},{"id":"0dc1b72f-056c-425f-9046-18ad98cd307c","order":77,"text":"Signed by me in the presence of two adult witnesses who were present at the same time, neither of whom is a person appointed by me under this document. So that this document is valid both as my advance care directive and as my appointment of a medical treatment decision maker (and support person, if any), at least one of the two witnesses is a registered medical practitioner, that requirement being the stricter of the two applicable witnessing requirements under the Act.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"8306dc30-5ef2-4636-84dd-6e591280ed97","order":78,"text":"This document was completed in full before it was signed, and I, the two witnesses and (where applicable) the interpreter each signed in the presence of one another.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"3260f3a5-318c-41fc-b25b-9d831a846f96","order":79,"text":"Signed at [Place of signing] on [Date of signing].","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"2b6b09b8-31da-4718-b212-0b045b4f4ca7","order":80,"text":"I have signed this document myself.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"8dabbcfc-caf6-46d8-9cf1-447d74546290","value":"self","type":"add","operator":"="}]},{"id":"4bc97f5e-8a36-4aa1-be1e-e1980940c7a5","order":81,"text":"As I am unable to sign because of a physical condition, I have directed [Full name of person signing at your direction], who is not a witness to this document, to sign it on my behalf, in my presence and at my direction.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"8dabbcfc-caf6-46d8-9cf1-447d74546290","value":"directed","type":"add","operator":"="}]},{"id":"73082cd8-d948-45ab-a090-68344b029f4f","order":82,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true},{"id":"75136014-ea9a-46f8-ae95-b43d3a8c8dc7","order":83,"text":"Signature of [Full name], or of the person signing at that person's direction","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"55d288ea-79b4-4867-b8f6-ccabe29817b2","order":84,"text":"Interpreter statement","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"f268ebca-6985-4e46-8f29-a08e90b8f54e","value":"Yes","type":"add","operator":"="}]},{"id":"5a7a0fd2-d1a9-41cd-a300-fbf7acc955a3","order":85,"text":"I, [Interpreter full name], an accredited interpreter, certify that I accurately interpreted this document and any relevant discussion for the person, and that the person appeared to understand the nature and effect of each statement in this document.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"f268ebca-6985-4e46-8f29-a08e90b8f54e","value":"Yes","type":"add","operator":"="}]},{"id":"7737a748-676c-4cd1-a871-9421b156821f","order":86,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true,"displayConditions":[{"field":"f268ebca-6985-4e46-8f29-a08e90b8f54e","value":"Yes","type":"add","operator":"="}]},{"id":"8253a5aa-a9e2-4bfa-ba87-987b635a97e1","order":87,"text":"Signature of interpreter","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true,"displayConditions":[{"field":"f268ebca-6985-4e46-8f29-a08e90b8f54e","value":"Yes","type":"add","operator":"="}]},{"id":"06660752-18ec-4d8c-ae5e-754837d119cc","order":88,"text":"Certification of Witness 1 (registered medical practitioner)","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"c98108dc-28c4-4207-bbc9-b62294fd8d13","order":89,"text":"I certify that: the person signed this document in my presence and in the presence of the other witness; the person appeared to me to have decision-making capacity in relation to each statement in this document; the person appeared to understand the nature and effect of each statement; and the person appeared to sign the document freely and voluntarily. I am a registered medical practitioner and I am not a person appointed under this document.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"22e84b04-a3aa-42f1-99f7-3591af8ca230","order":90,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true},{"id":"12fa56a1-b327-4320-a006-ac13344639e5","order":91,"text":"Name and signature of Witness 1 (registered medical practitioner)","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"80bf6971-c131-4647-9dfe-f9f3903a6909","order":92,"text":"Certification of Witness 2","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"94a07f4f-da9c-4c7e-95a5-534c4c9db0d7","order":93,"text":"I certify that: the person signed this document in my presence and in the presence of the other witness; the person appeared to me to have decision-making capacity in relation to each statement in this document; the person appeared to understand the nature and effect of each statement; and the person appeared to sign the document freely and voluntarily. I am at least 18 years of age and I am not a person appointed under this document.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"bbeed67d-e3bb-4510-a7ec-9373d3997d0e","order":94,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true},{"id":"a163f398-0446-4911-b015-e21e18085588","order":95,"text":"Name and signature of Witness 2","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"30","cflou":false,"active":true},{"id":"8e337c4d-4db3-46e7-9f3c-8fdf7dfb5162","order":96,"text":"Acceptance by medical treatment decision maker","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true},{"id":"23f732a5-44e8-4337-86c7-06f6f947571b","order":97,"text":"I acknowledge that I have been appointed as a medical treatment decision maker under this document. I understand the nature and effect of the appointment, and that when acting I must make the decision that I reasonably believe is the decision the person would have made. I sign this acceptance in the presence of an adult witness.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"6cd2452a-e118-4757-b34e-95737bff8366","order":98,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true},{"id":"9f1647d9-12b2-42ef-9d3e-0034ca009372","order":99,"text":"Name and signature of medical treatment decision maker","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true},{"id":"4de7067a-b27b-4e93-a84f-001eb77a4d43","order":100,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true},{"id":"0116c209-44e5-4213-8e51-54543e0a6724","order":101,"text":"Name and signature of witness to the acceptance","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true},{"id":"b291d241-e60c-4b51-9833-ba3138213916","order":102,"text":"Acceptance by support person","fontSize":"14","textAlign":"left","bold":true,"underline":false,"marginBottom":"5","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"6e1c046f-29b0-47dd-a339-f87c6faa0f0e","order":103,"text":"I acknowledge that I have been appointed as a support person under this document, and I understand the nature and effect of the appointment. I sign this acceptance in the presence of an adult witness.","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"b99214bd-11bd-4f8c-ae38-02747d531003","order":104,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"166e27fb-aff5-41c1-b8f6-9be0d9e080f9","order":105,"text":"Name and signature of support person","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"10","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"931a8f2a-2b45-4999-9583-5f7b0b8d2ccd","order":106,"text":"_______________________________________","fontSize":"14","textAlign":"left","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"019b5685-a611-4a10-9f55-490923042755","order":107,"text":"Name and signature of witness to the acceptance","fontSize":"12","textAlign":"left","bold":false,"underline":false,"marginBottom":"20","cflou":false,"active":true,"displayConditions":[{"field":"4854ef2d-1bb8-4db3-8aa8-574776a48c68","value":"Yes","type":"add","operator":"="}]},{"id":"9559effc-d2b7-4211-8d3b-c802d53d80d5","order":108,"text":"Advance Care Directive made under the Medical Treatment Planning and Decisions Act 2016 (Vic) — confidential.","fontSize":"10","textAlign":"center","bold":false,"underline":false,"marginBottom":"0","cflou":false,"active":true,"isFooter":true}]