Advance Care Planning - Residential Aged Care
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Advance Care Planning

What is Advance Care Planning?

Advance care planning is a process of planning for future health and personal care whereby a person’s values, beliefs and preferences are identified so they can guide decision-making at a future time when the resident is unable to communicate their decisions.1

An advance care planning discussion will often result in an advance care plan. Advance care plans state preferences about health and personal care and preferred health outcomes. Decisions may be made on the person’s behalf, but a person’s wishes should be used to guide the decisions.

Advance Care Planning - ELDAC Care Model

What is an Advance Care Directive?

Advance Care Directives are one way of formally recording an advance care plan. An Advance Care Directive is a type of written advance care plan recognised by common law or authorised by legislation that is completed and signed by a competent adult. An Advance Care Directive can record the person’s preferences for future care and appoint a substitute decision-maker. A substitute decision-maker is a person identified by law as able to make substitute decisions on behalf of someone who does not have capacity to make decisions. There can be more than one substitute decision-maker appointed.

Advance Care Planning Resources

Advance care planning and advance care directives are governed by state and territory legislation. The Advance Care Planning Australia website has information for each state or territory.

Advance Care Planning Australia (ACPA) has video resources, webinars, and support materials available that may assist in starting an advance care planning conversation. ACPA also has resources that can be downloaded and printed:

The ACPA’s National Advance Care Planning Support ServiceTM on 1300 208 582 is available to both healthcare workers and the community. The phone service operates 9am - 5pm (AEST) Monday to Friday, or find further information about contacting ACPA.

ELDAC Toolkit Educational Video

Watch the ELDAC Residential Aged Care Toolkit educational video on Recognise End of Life, which also discusses advance care planning.

Advance Care Planning Resources for Diverse Populations

Dementia Australia offers information on Planning Ahead to assist people living with dementia to plan for when they may no longer be able to make decisions on their own. Planning ahead can include communicating decisions related to finances, lifestyle, or healthcare and to put those decisions into action. Topics covered include:

  • Plans a person might need to take
  • Communicating wishes
  • Documenting decisions
  • Review plans.

Advance Care Planning Australia (ACPA) has information and resources on advance care planning and dementia.

Further information about dementia and advance care planning is available in the ELDAC Dementia Toolkit.

Advance Care Planning Australia offers information on advance care planning with web pages dedicated to a range of languages, including factsheets and translated audio files that can be shared.

Advance Care Planning Australia (ACPA) has information and resources on advance care planning for Aboriginal and Torres Strait Islander Peoples.

A report from the Australian Department of Health called Exploratory Analysis of Barriers to Palliative Care – Issues Report on Aboriginal and Torres Strait Islander Peoples describes key barriers and promising approaches for improving Aboriginal and Torres Strait Islander peoples’ experience of palliative care in Australia. It covers advance care planning and ways the palliative care sector can improve access and quality of care for this group.

The Dying to Talk discussion starter website was designed by Palliative Care Australia (PCA) to help people to begin the conversation about how they want to be cared for and what their wishes and preferences are for their end of life. There is a version designed for Aboriginal and Torres Strait Islander communities, including a downloadable booklet and online card game to facilitate the conversation.

Some LGBTI people are not in close contact with their biological family, have no children, or have children who do not accept their life decisions. These factors can impact on their healthcare at critical times in their life. The Australian Department of Health has a report available in relation to palliative care for LGBTI people in Australia entitled The Exploratory Analysis of Barriers to Palliative Care: Issues Report on People who Identify as Lesbian, Gay, Bisexual, Transgender or Intersex (2019). The report describes recommendations for improving palliative care access and the quality of care for the LGBTI community. Key points on advance care planning are covered (pages 20-22), including barriers facing this group and enablers for change.

Advance Care Planning Australia (ACPA) has information and resources on advance care planning for the LGBTI+ community.

  • Forms and Templates
  • Family Resources

Forms and requirements for writing advance care plans and appointing substitute decision-makers vary between and states and territories. Advance Care Planning Australia provides information for Australian states and territories.

Advance Care Planning Australia (ACPA)

ACPA has comprehensive resources on understanding advance care planning for individuals and family, friends and carers, including these key resources:

Planning Ahead

Dementia Australia offers information on Planning Ahead to assist people living with dementia to plan for when they may no longer be able to make decisions on their own. Planning ahead can include communicating decisions related to finances, lifestyle, or healthcare and to put those decisions into action. Topics covered include:

  • Plans a person might need to take
  • Communicating wishes
  • Documenting decisions
  • Review plans.
Dying to Talk Discussion Starter
The Dying to Talk discussion starter website was designed by Palliative Care Australia (PCA) to help people to begin the conversation about how they want to be cared for and what are their wishes and preferences for their end of life. Talking in advance can help reduce stress when someone is very sick and can help families make decisions about care if their loved one is no longer able to make them. The website also includes links to people’s personal stories. There are links to the Discussion Starter online, which is a downloadable booklet and online card game to facilitate the conversation. There is also a version of these materials designed for Aboriginal and Torres Strait Islander communities.
Start the Conversation
The Australian Government Department of Health has a Start the Conversation web page and video with advice on talking about dying with loved ones and finding out their wishes to prepare for the care they want to receive at the end of life.