Advance Care Planning

Tips for Careworkers:
Advance Care Planning

What it is: Advance care planning (ACP) is where a person plans for their future care by discussing and/or recording their preferences and values. An Advanced Care Directive (ACD) is a written advance care plan. In different states of Australia an ACD may have a different name. An ACD may include care preferences and values, and instructions about future treatment. What can be included and the forms to be used depends on the relevant state or territory law. An older person can name someone to make decisions for them if later they are unable to. This person is called a substitute decision-maker (SDM). Some states and territories include this in an ACD.

Why it matters: Advance care planning helps people receive the care that they would want to receive. Writing down preferences is important because if a person can no longer make or express decisions, the people around them will know what they would want. Careworkers can support older people and their families by referring questions about ACDs to nursing/supervisory staff.

What I need to know: A person does not have to plan or have an ACD. An ACD is only used if the person cannot make or express decisions.

ACDs can be changed whenever the person wants to change them or when their health or circumstances change.

A person may choose to refuse treatment. This is not giving up and does not mean that care will stop. It means the focus of care will be on comfort, dignity and the support of the person and their family and carer(s).


Make sure that a current ACD accompanies the older person moving to or from hospital or place of care.



Make sure you have the contact details of the:

  • substitute decision-maker
  • person to contact in case of an emergency.

These may not be the same person.



If someone wants to discuss health planning, tell nursing/supervisory staff.


My reflections:


Can an Advanced Care Directive (ACD) be changed?

What should I do when an older person is moved to a new place for care?

Have I thought about advance care planning for myself or my family?

See related palliAGED Practice Tip Sheets:

After-Death Choices

Palliative Care

Talking about Dying


For references and the latest version of all the Tip Sheets visit


CareSearch is funded by the Australian Government Department of Health. Updated April 2022

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