Advance Care Planning (ACP)

What we know

Advance care planning (ACP) can improve end-of-life care in line with a person’s wishes. ACP can enable a person’s wishes to be known when they can no longer speak for themselves.

ACP is a beneficial process for all adults, particularly for those with chronic or life-threatening illness whose health is likely to deteriorate. However, not all adults have an advance care plan (ACP) or advance care directive (ACD) and may not have even discussed their wishes or preferences with those close to them. In Australia, it is important to be aware of the relevant state and territory government laws on ACP and ACDs.

The palliAGED specific needs pages can help you to find resources designed to support ACP for particular groups.

Go to Evidence Summary

What can I do?

You can use the ACP information in palliAGEDnurse (available free-of-charge as an app or online through your web browser).

Understand what your role can be in advance care planning.

Suggest that older people and their family consider advance care planning. The advance care planning process and Starting the conversation can help guide discussions and decisions around advance care planning.

Explore the 'What Matters Most for Older People' resources with the older person and their family view.

Suggest that the older person and their family use the 'Aboriginal and Torres Strait Islander Discussion Starter' to begin discussions about what is and isn't important to them.

For people in your care and their families, make available the fact sheet about advance care planning for individuals (193kb pdf) and the factsheet for substitute decision-makers (259kb pdf).

For your clients or residents, ensure that the Advance Care Plan (ACP) or Advance Care Directive (ACD) can be found quickly and easily. Make sure the contact details are up to date for the next-of-kin, the substitute decision-maker and the person to contact in case of an emergency; these may not be the same person.

An ACP can include what to do in an emergency.

Before organising a hospital transfer, confirm the client’s or resident’s wish.

Ensure that the current care plan and documents such as an ACD go with a client or resident when transferred in an emergency.

Advance care planning information can be uploaded to My Health Record.

After a health emergency or a hospital admission, review the care plan and ACP/ACD. A family meeting may be helpful.

palliAGED Tip sheets

Tips for Careworkers:
Advance Care Planning

Tips for Nurses:
Advance Care Planning

What can I learn?

Check out the quick guide for health professionals to identify the relevant freely available resources to support advance care planning for people in your care.

Complete one of The Advance Project online training modules designed to support GPs, general practice nurses and practice managers in the provision of palliative care and advance care planning (ACP) in everyday general practice

Check out these websites:

Advance Care Planning Australia including Create your plan for each State and Territory.
Advance Care Planning (resources with general applicability and some specific to dementia and other forms of cognitive decline)
End of Life Law in Australia

Read:

Scott IA, Mitchell GK, Reymond EJ, Daly MP. Difficult but necessary conversations--the case for advance care planning. Med J Aust. 2013;199(10):662–666. doi: 10.5694/mja13.10158
Take control over the end of your life: what you need to know about advance care directives
Gilissen J, Pivodic L, Smets T, Gastmans C, Vander Stichele R, Deliens L, et al. Preconditions for successful advance care planning in nursing homes: A systematic review. Int J Nurs Stud. 2017 Jan;66:47-59. doi: 10.1016/j.ijnurstu.2016.12.003. Epub 2016 Dec 8.

What can my organisation do?

Aged care providers, particularly managers and senior staff can use the advance care planning in aged care guide (2.38MB pdf) to support implementation in community and residential settings.

So that care is in line with clients’ and residents’ wishes and preferences, ensure that the organisation has clear processes

for people with capacity to document their preferences for care
for people who no longer have capacity, that substitute decision-makers are contacted
for care plans to be regularly reviewed.

Train staff to introduce discussion around advance care planning and offer contact details of people who can provide assistance in this process.

Ensure there is a process of integrating an Advance Care Plan (ACP) or Advance Care Directive (ACD) into notes, records and the goals of care.

Make sure that a copy of the ACD is readily available in notes or records.

An electronic version of ACP documents may assist accessibility by various people and organisations which provide care; My Health Record may be useful.

Page updated 07 July 2021