GuidetoAdvance
Statement
Contents
1. AdvanceStatement…………………………………………………………………………………….
2. Whatistreatment………………………………………………………………………………………
3. BenefitsofanAdvanceStatement……………………………………………………………..
4. MakinganAdvanceStatement…………………………………………………………………..
5. ContentofanAdvanceStatement……………………………………………………………..
6. TipsandIdeas………………………………………………………………………………………….…
7. OverridinganAdvanceStatement……………………………………………………………..
8. RevokinganAdvanceStatement………………………………………………………………..
9. SharingandAccessinganAdvanceStatement…………………………………………..
10. ReviewingyourAdvanceStatement…………………………………………………………
11. CostofanAdvanceStatement…………………………………………………………………
12. Furtherinformation………………………………………………………………………………….
Appendix1.FlowCharts………………………………………………………………………………….
Appendix2.AdvanceStatementTemplate…………………………………………………….
Appendix3.RevocationofanAdvanceStatementTemplate………………………….
Appendix4.Checklists……………………………………………………………………………………
Appendix5.GlossaryofTerms…….…….……………………………………………………………
TheVictorianMentalIllnessAwarenessCouncil(VMIAC)isthepeakrepresentativebodyforpeopleexperiencingmentalhealthor
emotionalissues.Aspartofourroleweconsultwithconsumertopromotetheirvoicesinmattersthataffectthem.
ThisdocumentwasdevelopedinconjunctionwithConsumerandConsumerWorkersandtheinformationprovidedisbasedon
informationwrittenintheVictorianMentalHealthAct(2014).
ThispublicationisalsoavailableasaPDFandonlineatwww.vmiac.org.au.ForfurtherinformationpleasephoneVMIAC,(03)93803900.
Exceptwhereotherwiseindicated,theimagesinthispublicationshowmodelsandillustrativesettingsonly,anddonotnecessarilydepict
actualservices,facilitiesorrecipientsofservices.ImagesinthisguidearefromtheScottishGovernment,TheMentalHealthAct:aneasy
read,whichcanbefoundathttp://www.scotland.gov.uk/publications/2007/09/03145057/2.NOTE:theScottishMentalHealthActdoes
nothaveanylegalstandinginVictoriaandisseparatetoVictoria.
AdvanceStatement
ThisguidesummarisesinformationaboutAdvanceStatementsundertheVictorianMental
HealthAct2014.
AnAdvanceStatementisastatementofyourtreatmentpreferencesintheeventyou
becomeunwellandrequirescompulsorymentalhealthtreatment;andarefindingitdifficult
toeffectivelycommunicateyourwishestoyourtreatingteam.
Apersonundertheageof18canmakeanAdvanceStatementaslongastheyunderstand
whatanAdvanceStatementisandwhattheoutcomeisifyoumakeastatement.
Whenyouareunwellitcanoftenbehardtothinkclearly,hardtotellpeoplewhatyouwant
andevenhardertogetsomeonetolisten;particularlyifyouaredeterminednottohave
decisionmakingcapacity.AnAdvanceStatementisanopportunityandformalwayforyou
tostateyourpreferences,toprovideanoverallunderstandingofyouasapersonandwhat
isimportanttoyou.
AnauthorisedpsychiatristmusthaveregardtoyourAdvanceStatementwheneverthey
maketreatmentdecisions.TheMentalHealthTribunalalsoneedstotakeyourAdvance
StatementintoconsiderationiftheyaremakingadecisionaboutaTreatmentOrderorECT.
Peoplewhoarereceivingvoluntarymentalhealthtreatmentmayalsofindthisauseful
measuretocommunicatetheirpreferences.
Whatistreatment?
Treatmentreferstotoolsusedtoalleviatesymptomsanddistresswhensomeoneis
consideredunwell.Electroconvulsivetherapy(ECT)medicationandpsychotherapylike
CognitiveBehaviouralTherapyareexamplesofclinicalmedicaltreatments.
Clinicalmedicaltreatmentdonotincludealternativetherapiesthatarethoughttohave
healingpropertiesbutarenotscientificallyproven(herbalmedicineorhomeopathy),but
youcanstillincludethisinformation.However,yourtreatingteamarenotrequiredto
consideralternativetreatmentpreferences.
Pleasesee‘GlossaryofTerms’fordefinitions.
BenefitsofanAdvanceStatement
AnAdvanceStatementishelpfulbecause:
Itclearlystateswhattreatmentsyouwouldlikeandwhattreatmentsyouwouldnot
like.
AnAdvanceStatementgivesyoutheopportunitytoexplainwhyyouhavechosenthese
treatmentpreferences.Whenapersonhasbecomeunwellandgonethroughrecovery,
theyknowwhattreatmentshaveworkedforthemandwhattreatmentshavecaused
unwantedsideeffects.
Informationthatisnotrelatedtoclinicaltreatmentdonothavetobeconsideredbyan
authorisedpsychiatrist.Thesepreferencesmaystillbeimportanttoyouandcanbe
includedintheinformationsectionofyouradvancestatement.Informationpertaining
toyourlife,thatyoufeelyourtreatingteamneedstobeawareofandaidinginyour
recovery.
AnAdvanceStatementgivesyoursupportpeopleinvolvedinyourtreatment,an
opportunitytohaveaclearunderstandingofyourpreferences,wishesandopinions.
MakinganAdvanceStatement
YoucanmakeanAdvanceStatementatanytime,aslongasyouunderstandwhatan
AdvanceStatementisandthepossibleoutcomewhenmakinganAdvanceStatement.
AnAdvanceStatementmust:
Beinwriting
Besignedanddatedbyyou
BewitnessedbyanAuthorisedWitness
IncludeastatementsignedbytheAuthorisedWitnessstatingthat-
- Intheiropinion,youunderstandswhatanAdvanceStatementisandthe
consequencesofmakinganAdvanceStatement
-ThewitnessobservedyousigntheAdvanceStatement
-ThewitnessisanAuthorisedWitness
AnAuthorisedWitnessmeansaregisteredmedicalpractitioner,amentalhealth
practitioner(anyclinicalmentalhealthstaffcurrentlyworkingatamentalhealthservice)or
anypersonwhocanwitnessastatutorydeclaration.
AnAuthorisedWitnessmaybe:
Psychiatrist
Psychologist
Nurse
SocialWorker
Occupationaltherapist
CaseManager
Anymedicalspecialist(includingaGeneralPractitionerGP)
Justiceofthepeace
Solicitor
PoliceOfficer
Sheriff
Dentist
Pharmacist
SchoolPrincipal
BankManager
RegisteredAccountant
Acommunitymentalhealthsupportworker,canassistyoutocompleteyourAdvance
Statementbutcannotwitnessit.Acommunitymentalhealthsupportworkermaybe:
Peer-SupportWorker
PersonalHelpersandMentorsworker
Out-reachsupportworker
PartnersInRecoveryWorker
LifeCoaches
Theauthorisedwitnessdoesnotneedtoagreeorapprovethepreferencesyouhavelisted
inyourAdvanceStatement.
ContentofanAdvanceStatement
ThecontentofanAdvanceStatementmayincludebutisnotlimitedto:
Atreatmentyoufindeffective.
Atreatmentyouhavefoundnottobeeneffective.
Otherinformationaboutyourmentalhealthcareandtreatment,includinganymental
healthservicesorclinician’syouarecurrentlyworkingwith.
Anyotherexistingmedicalconditionsyoumayhave,includingtreatmentand
medication.
Whatyouwouldliketohappenifyouareadmittedtohospital,includingtreatment
preferences.
YourviewsandpreferencesaboutElectroconvulsiveTherapy(ECT).
Yourviewsaboutseclusionandrestraint,includingmeasurestotaketoavoidtheuseof
restrictiveinterventions.
WhoisyourNominatedPersonandtheircontactdetails?
Aspreviouslystated,youmaywishtoincludeanyadditionalinformationyoufeelis
importantforyourtreatingteamshouldknow;includingpeopleyouwouldliketobe
notifiedshouldyoubeadmittedtohospitalandtheneedsofdependentpeopleor
animals.Howeverthereisnolegalobligationforanauthorisedpsychiatristtoeffect
thesepreferences.
TipsandIdeas
AnAdvanceStatementwillbeuniquetoyouasitisbasedonyourrecoverystory.An
AdvanceStatementisawaytoprovidea‘snapshot’ofyouwhenyouarewell.
Thefollowingaresometipsandideasyoumaywishtoincludeinthe‘informationsection’
ofyourAdvanceStatement.
Youmaywishtoinclude:
ThatyourNominatedPersonistobenotifiedimmediatelyifyouareadmittedto
hospital.
Thatyourmother/father/brother/sister/husband/wifeorpartnerbenotifiedifyouare
admittedtohospital.
YourMentalHealthAdvocateistobenotifiedifyouareadmittedtohospital
Youmaywishtoincludeinstructionsonwhoistocareforyourdependent
children/peopleorpets.
Youmaywishtoincludecommonbehaviours-forexample-youmaybeanindividual
wholikestoreadbooks;thatyoucansitandreadagoodbookforseveralhoursand
thatyoumightnottalk,eatordrinkwhenyouarereadingabook.Thisdoesnotmean
thatyouarenotengagingwithcliniciansordepressed.Youmightbeanindividualthat
wandersaroundsigning.Thisdoesnotmean,youhaveanelevatedmood,itis
somethingyoudoeveryday.
Youmaywishtoincludethingsthatcantriggeracertainemotionandhowtoavoid
these‘triggers’.
Youmaywishtoincludetechniquesthathelpyourelax.
Youmaywishtoinformthestaffofanyspecialdietaryrequirementsyouhave.
Youmaywishtoincludeanyspiritualorreligiousaffiliations.
Youmaywishtoincludeinstructionsonanybillsorrentthatneedtobepaid.For
example,gasandelectricitybills.
Tohaveyourrightsasanindividualreceivingcompulsorymentalhealthtreatment
communicatetoyouonaweeklybasis;becauseyoumightbesufferingfrommental
fatigueduetomedication.
Thatanytreatmentdecisionswillbemadecollaborativelywithyournominatedperson,
career,familymember,supportfriendorMentalHealthAdvocateintheroomwithyou.
Youmaywishtoincludethatyouhaveexperiencedtraumainthepast,andstaffareto
beawareofthisbeandsensitivetoyourneeds,whenworkingwithyou.
Thatanauthorisedpsychiatrististoprovideyouwithawrittenstatementstatingwhy
theyhavenotimplementedyoutreatmentpreferences.
AnAdvanceStatementthatincludestreatmentpreferencesandadditionalinformation,
providesinformationtothetreatingteamaboutyou.Itisadvisabletoexplainwhyyouhave
voicedthesepreferencestohelpyourtreatingteambetterunderstandyourwishes.
OverridinganAdvanceStatement
Ifanauthorisedpsychiatristfeelsyourtreatmentpreferencesarenotclinicallyappropriate
ornotofferedbythementalhealthservicetheycanoverrideyouradvancestatement.
Clinicallyappropriateiswhereanauthorisedpsychiatristneedstodetermineifthe
treatmentpreferencesyouhavelistedaretreatmentscommonlyusedandacceptedin
medicalpracticeandbasedoncrediblescientificevidence.
IftheauthorisedpsychiatristoverridesyourAdvanceStatement:
Theymusttellyou.
Explaintheirreasonswhy.
Informyouthatyoucanrequestawrittenstatementofreason/sfortheirdecisionsnot
tonotfollowtheirAdvanceStatement.
Ifyourequestsastatementofreasons,theauthorisedpsychiatristmustprovideone
within10businessdays.
Ifyouhaveanyconcernsorarenotsatisfiedwiththereason/sprovided,youcanlodgea
complaintwiththeMentalHealthComplaintsCommissioner.Pleaseseethe‘further
information’sectionofthisguideformoredetails.
Aspreviouslystated,theMentalHealthTribunalalsohastoconsideryourtreatment
preferenceswhenmakingaTreatmentOrderorECT.Ifyoudisagreewiththeirdecisionyou
canappealtheirdecisiondirectlytotheboardortakethemattertotheVictorianCiviland
AdministrativeTribunalincaseswhereanorderforECThasbeengiven.
RevokinganAdvanceStatement
Ifyouwouldliketochangeyourtreatmentpreferencesandadditionalinformationinyour
AdvanceStatement,itcannotbealtered,itmustberevoked.‘Revoking’meanstoofficially
withdrawthetreatmentpreferencesandadditionalinformationyouhavepreviouslylisted
intheirAdvanceStatement.
TorevokeanAdvanceStatement:
Itmustbeinwriting.
Besignedanddatedbyyou.
Includeastatement
-ThepreviousAdvanceStatementisnolongervalidandisrevoked.
BewitnessedbyanAuthorisedWitness.
IncludeastatementsignedbytheAuthorisedWitnessstatingthat-
- Intheiropinion,youunderstandswhatanAdvanceStatementisandthe
consequencesofrevokinganAdvanceStatement.
-ThewitnessobservedyourevokingtheAdvanceStatement.
-ThewitnessisanAuthorisedWitness.
OnceanAdvanceStatementhasbeenrevoked,youcanmakeanewAdvanceStatementby
followingthestepspreviouslylisted.MakinganewAdvanceStatementwillcanceloutthe
oldAdvanceStatement.
SharingandAccessinganAdvanceStatement
AnAdvanceStatementgivesyournominatedperson(ifyouhaveone),familymembers,
careers,currentmedicalprofessionals(includingGeneralPractitionerandmentalhealth
clinicians/treatingteam),andsupportworkersanopportunitytohaveaclear
understandingofyourpreferences,wishesandopinions.YourAdvanceStatementisavery
personalmedicaldocumentandthereforeshouldonlybegiventopeoplewhoareinvolved
inyourcare.
ItisadvisablethatindividualsinvolvedinyourcareareawareyouhaveanAdvance
Statement(orrevokedAdvanceStatement).Also,thattheyhaveacopyofyourAdvance
Statement(orrevocationofanAdvanceStatement)incaseyoubecomeunwellandneed
compulsorymentalhealthtreatment.YourAdvanceStatementshouldbekeptinaplace
thatiseasytofind.
ItisadvisableforyoutogivepermissionforyourAdvanceStatementtobepartofyour
patientfile,sothatitcanbeaccessedbydifferentdepartmentsofthedesignatedmental
healthservice(forexampleintheEmergencyDepartment).
Youcanaskyourlocaldesignatedmentalhealthservicetoregisterthatyouhavean
AdvanceStatementontheirelectronicrecordsystem.
ReviewingyourAdvanceStatement
YoudonotneedtoreviewyourAdvanceStatement,butbyregularlyreviewingit,itensures
thatyourtreatmentpreferencesandadditionalinformationisup-todate.
YoumightreviewyourAdvanceStatementafter:
Youhavebeenunwell.
Ifyouhavebeenreceivingcompulsorymentalhealthtreatmentinadesignatedmental
healthservice.
Iftherehasbeenachangeinyourdiagnosis,treatment,ormedication.
Iftherehasbeenamajorlifeeventorphysicalhealthchanges.Forexample,ifyouwere
tochangeyournameorsufferaphysicalillness.
Pleasesee‘GlossaryofTerms’fordefinitions.
CostofanAdvanceStatement
ItisfreetomakeanAdvanceStatement,howeversomepeoplemaychargeyoufortheir
timeandhelptocompleteorwitnessyourAdvanceStatement.
Pleasesee‘GlossaryofTerms’fordefinitions.
FurtherInformation
ForfurtherinformationandhelpwithyourAdvanceStatementpleasecontactthefollowing
organisations:
TheDepartmentofHealthVictoria–AdvanceStatementsavailablefrom:
http://www.health.vic.gov.au/mentalhealth/mhact2014/recovery/advance-
statements.htm
VMIAC:Phone(03)93803900,http://www.vmiac.org.au/
Tandem:Phone(03)88035555,http://tandemcarers.org.au/
TheMentalHealthTribunal:Phone(03)90323200,http://www.mht.vic.gov.au/
TheMentalHealthComplaintsCommissioner:Phone1800246054,
http://www.mhcc.vic.gov.au/
ADVANCESTATEMENT
FLOWCHART
STARTHERETOMAKEAN
ADVANCESTATEMENT
Adocumentoutliningaperson’s
treatmentpreferencesandadditional
informationintheeventtheybecome
unwellandrequirecompulsory
mentalhealthtreatment
Mustbeinwriting
AND
Mustbesignedanddatedbythe
personmakingtheadvance
statement
AND
Mustincludeastatement
signedbyanauthorised
witnessthat:
Intheiropinion,theperson
understandswhatan
advancestatementisand
theconsequencesof
makingthestatement
AND
Thepersonsignedthe
advancestatementinthe
presenceofthewitness
FINISHED!
REVOKINGANADVANCE
STATEMENTFLOWCHART
STARTHERETOREVOKEAN
ADVANCESTATEMENT
Therevocationofanadvancestatement: Mustbeinwriting
AND
Mustbesignedanddatedbythe
personrevokingtheadvance
statement
AND
Mustincludeastatementsignedby
anauthorisedwitnessthat:
Intheiropinion,theperson
understandsthe
consequencesofrevokingthe
advancestatement
AND
FINISHED!
Thepersonsignedtherevocationofthe
advancestatementinthepresenceofa
witness
ADVANCESTATEMENTTEMPLATE
THEAdvanceStatementof……………………………………………………………
FullName
DateofBirth
Address
Primarymentalhealth
worker/supportworker
Primarymentalhealth/
supportworker’sphone
numberandaddress
Psychiatrist
Psychiatristphonenumber
andaddress
GeneralPractitioner(GP)
GeneralPractitioner(GP)
Phonenumberandaddress
Healthteam/syouare
currentlyworkingwith
Familymembers,carers,
peerworker/s,and/or
supportpeopleinvolvedin
yourrecovery.
Familymembers,carers,
peerworker/s,and/or
supportpeoplewhohavea
copyofyourAdvance
Statement
DATE:………………/……………………./…………………….
SIGNATURE:…………………………………………………….
ADVANCESTATEMENTTEMPLATE
THEAdvanceStatementof……………………………………………………………
IfIbecomeunwellandrequirecompulsorymentalhealthtreatment….
Mytreatmentpreferencesare…
Thereasonsforthese
preferencesare…………..
DATE:………………/……………………./…………………….
SIGNATURE:…………………………………………………….
ADVANCESTATEMENTTEMPLATE
THEAdvanceStatementof…………………………………………………………..
IfIamplacedon
anorder,Iwould
likeyouto
contact………………..
Relationshipto
you(Family
member,carer,
guardian,
nominated
person)
PhoneNumber
Address
DATE:………………/……………………./…………………….
SIGNATURE:…………………………………………………….
ADVANCESTATEMENTTEMPLATE
THEAdvanceStatementof……………………………………………………………
ADDITIONALINFORMATION
Youcanaddand/orattachadditionalinformationtoyourAdvanceStatement,including
informationthatisimportantforyourtreatingteamtoknow.Forexample,peopleyouwould
liketobenotifiedshouldyoubeadmittedtohospitalandtheneedsofdependentpeople
oranimals
Iunderstandthattheinformationbelowarenotconsideredclinicaltreatmentpreferencesbutis
importantinformationIfeelmytreatingteamneedstoknowtoaidinmyrecovery.
Mypersonalpreference/sandthereasonsformypersonalpreferenceareasfollows:
DATE:………………/……………………./…………………….
SIGNATURE:…………………………………………………….
ADVANCESTATEMENTTEMPLATE
THEAdvanceStatementof……………………………………………………………
ADVANCESTATEMENTWITNESSDECLARATION
Inmyopinion,thepersonmakingthisAdvanceStatementunderstandswhatanAdvance
StatementisandtheconsequencesofmakingthestatementandIhaveobservedtheabove
namedpersonsigningtheAdvanceStatement.
WitnessName:
WitnessstatusasanAuthorisedWitness:
(Example…Psychologist/nurse/G.P)
Witnessphonenumberandaddress:
Thosewhocanactasawitnessare:(a)aregisteredmedicalpractitioner;or(b)amentalhealth
practitioner;or(c)apersonwhomaywitnessthesigningofastatutorydeclarationundersection
107AoftheEvidence(MiscellaneousProvisions)Act1958.Includingbutnotlimitedto:
Psychiatrist,Psychologist,OccupationalTherapist,RegisteredPsychiatricNurse,Chemist,
bankmanager,socialworkerandG.P
WITNESSSIGNATURE:
DATE:……………../…………………./…………………..
DATE:………………/……………………./…………………….
SIGNATURE:…………………………………………………….
ADVANCESTATEMENTREVOCATION
TEMPLATE
ADVANCESTATEMENTREVOCATION
IFyouwanttochangeornolongerwishtouseyourpreviousadvancestatementyoumustfillin
arevocationform.Thismustalsobewitnessedbyanauthorisedwitnessandletindividuals
involvedinyourcareknowyouhaverevokeditandmadeanewadvancestatement.
I, (name)wishthatmyAdvanceStatement,completedon
(date),berevoked,asitisnolongerreflectsmydesired
treatmentpreferencesandadditionalinformation.
SIGNATURE:……………………………………………………………………
DATE:……………………/………………………../……………………………….
REVOCATIONOFADVANCESTATEMENTWITNESSDECLARATION
IhavewitnessedtheabovenamedpersonrevokingthisAdvanceStatementandIamsatisfied
theyunderstandtheconsequencesofrevokingtheAdvanceStatementandhaveobservedthe
personsigningtherevocation.
AuthorisedWitnessName:
WitnessstatusasanAuthorisedWitness:
(Example…Psychologist/nurse/G.P)
Witnessphonenumber:
Witnessaddress:
WITNESSSIGNATURE:…………………………………………………………………………..
DATE:…………………../…………………………/…………………………
Checklist
The following is a checklist of actions to complete when writing your Advance
Statement
Before you write your Advance Statement
Have you thought about what treatment preferences you would like?
Have you thought about what additional information is important for your
treating team to know?
If you have people that support or care for you, have you discussed the use of
Advance Statement’s in your recovery? (OPTIONAL)
Do you have someone to assist you in completing your Advance Statement?
(OPTIONAL)
Have you thought about who could be your authorised witness?
o Will they charge a consultation fee?
Writing your Advance Statement
Is it in writing?
Have you listed your treatment preferences; including your opinions around the
use of ECT, seclusion and restraint?
Have you included any important additional information you would like your
treating team to know; including any tips and ideas listed in this guide?
Have you listed any important people involved in your care and support, along
with their contact details?
Have you listed any current medical professional you are currently working with,
along with their contact details (Both physical and mental health)?
Have you listed any medication you may take or therapy you are currently
trying?
Have you listed any clinical treatments that have not been helpful in the past or
caused unwanted side-effects?
Have you listed the reasons for your chosen treatment preferences and/or
additional information given?
Is it signed and dated by you in the presence of an authorised witness?
Does it include a statement signed by the authorised witness stating that;
o In their opinion you understand what an Advance Statement is and the
consequences of making an Advance Statement
o The witness observed you sign the Advance Statement
o The witness is an Authorised Witness
After you have written your Advance Statement
Have you told people that are involved with your care and support that you have an
Advance Statement?
Have you given a copy of your Advance Statement to any mental health worker,
specialist, G.P, support worker, advocate, carer, guardian or designated mental
health service you are currently working with?
Have you stored your Advance Statement in a safe and easily located place?
Have you given permission for your Advance Statement to be a part of your patient
file?
Are you registered in your local designated mental health service as having an
Advance Statement?