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Home Care Clinical Care Assess Your Knowledge Organisational SupportResidential Aged Care Assess Your Knowledge Clinical Care
- Advance Care Planning
- Recognise End of Life
- Assess Palliative Care Needs
- Provide Palliative Care
- Work Together
- Respond to Deterioration
- Manage Dying
- Bereavement
End of Life Law Toolkit Capacity and Consent to Medical Treatment Factsheet: Advance Care Directives Futile or Non-Beneficial Treatment Legal Protection for Administering Pain and Symptom Relief Managing Disputes about Medical Treatment Decision-Making Substitute Decision-Making Urgent Medical Treatment Voluntary Assisted Dying Withholding and Withdrawing Life-Sustaining Medical Treatment Overview of End of Life Law in Australia Advance Care DirectivesHome Care Residential Aged CareAssess Your Knowledge Clinical CareEnd of Life Law Toolkit Dementia Toolkit Education Other ToolkitsAdvance Care Planning Recognise End of Life Assess Palliative Care Needs Provide Palliative Care Work Together Respond to Deterioration Manage Dying BereavementOrganisational SupportManage Dying
Advance care planning (ACP) is a process of planning for future health and personal care whereby a person’s values, beliefs and preferences are identified. This can help guide decision-making at a future time when an older person is unable to communicate their decisions. [1]
Ideally, ACP will result in an older person’s preferences being recorded in a legal document known as an Advance Care Directive (ACD). The appointment of a substitute decision-maker can help ensure that preferences are respected. [2]
General Practitioners or care partners often initiate or lead conversations about advance care planning with older people at home. If the person has had admissions to hospital or is known to a specialist palliative care service these practitioners may have discussed advance care planning. However, all workers involved in home care will need to have a broad understanding of this topic.
Undertaking ACP can:
- Ensure future decisions about the care of an older person are more likely to reflect their preferences and values.
- Ensure that the older person’s health professionals are aware of their wishes and preferences. Also, that those who may have to make decisions on the older person’s behalf in future, such as substitute decision-makers, are aware of that person’s wishes and preferences.
- Assist health professionals, families and carers to have planning conversations.
- Explore issues about the care and death of an older person in a supported way.
- Improve end-of-life care, satisfaction with care provided, and communication with care workers and health professionals.
- Reduce the risk of moral distress and conflict at the end of life for families and carers. [3, 4]
An Advance Care Directive is a legal document that a person with decision-making capacity makes about future health care. Depending on the State or Territory, it can be used to:
- make specific decisions about medical treatment, such as refusing life-sustaining treatment
- express preferences and values about medical treatment and care
- appoint a substitute decision-maker. [5]
An Advance Care Directive can only be followed when the person no longer has capacity for the decision (except in the Australian Capital Territory). The ELDAC End of Life Law Toolkit has a factsheet that covers Advance Care Directives in more detail.
Consent must be obtained before a person receives medical treatment or undergoes a medical examination.
A person may consent to or refuse medical treatment if they have decision-making capacity. ‘All adults are presumed to have capacity to consent to or refuse treatment, unless it can be shown that they do not. A person will have capacity for a medical treatment decision if they can:
- comprehend and retain the information needed to make the decision, including the consequences of the decision; and
- use and weigh that information as part of their decision-making process.’ [6]
The ELDAC End of Life Law Toolkit has a factsheet providing an overview on Capacity and Consent to Medical Treatment.
A substitute decision-maker is a person with legal authority to make a decision on behalf of an older person who does not have capacity to decide. If the older person or a Tribunal has not appointed a substitute decision-maker, the law in each State and Territory sets out who can decide. This is usually a person’s family members or close friends so long as they have a close and continuing relationship with the person. [7]
The ELDAC End of Life Law Toolkit has a factsheet that provides information on Substitute Decision-Making.
Care partners should be aware of the name and contact details of an older person’s substitute decision-maker.
Supported decision-making allows a person who needs support to make their own decisions, such as an older person with cognitive impairment. [7] Examples of support include:
- providing information in a format they can understand
- giving the person more time to process and discuss the information with others
- talking through options with them, or
- communicating decisions made by the person to health professionals. [6]
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How to approach ACP in home care
ACP conversations should be:
- Introduced early in care relationships.
- A routine part of ongoing care planning for an older person.
- Aligned with the older persons expectations for care.
- Reviewed regularly, especially:
- where the older person expresses a wish to update or change their plan
- after an illness, accident, or admission to hospital
- when an illness progresses or someone is deteriorating.
If facilitating discussions about ACP is not within the scope of your role, identify who may be most appropriate to undertake these conversations. This may be a General Practitioner, care partner or a member of the specialist palliative care team.
Making an Advance Care Directive and ACP is voluntary. An older person can choose not to have a Directive or planning document if they prefer.
Consider:
- The person: Ideally, the older person should be medically stable, comfortable, and accompanied by their substitute decision-maker(s), family or carers.
- The location: Find a space within the home that is private and quiet to avoid interruptions.
- The approach: Consider simple words that you might use to begin to explore someone’s wishes and preferences. For example: ‘We often talk to people about what they would want if they became more unwell. Have you ever thought about this?’
Consider conversation starters and useful information:
- Talk about your choices by Advance Care Planning Australia, or the brief What is Advance Care Planning – Factsheet for Health Professionals (139kb pdf).
- What Matters Most Discussion Starter and Facilitator Guide by Palliative Care Australia has been designed for older people using aged care services and is available in several languages.
- The REDMAP Framework (928kb pdf) provides a 6-step guide to future care planning conversations. REDMAP stands for: Ready, Expect, Diagnosis, Matters, Actions and Plan.
There are relevant forms and templates that can be used to support planning. However, forms and requirements vary between states and territories for ACP, ACDs, and appointing substitute decision-makers. Your organisation or service may also have relevant documents and resources you can use to facilitate ACP.
- To learn about ACP documents, including ACDs in your state or territory, go to Advance Care Planning Australia’s Record Your Choices.
- Go to the ELDAC End of Life Law Toolkit for helpful information and resources on ACDs, case studies and mythbusters.
- The ELDAC Dementia Toolkit includes ACP resources to support people living with dementia.
- The ELDAC Our Diversity webpage has information and resources on supporting ACP for diverse groups.
ACP documents may be kept with the person, substitute decision-maker(s), their GP, or their home care provider.
Advance Care Directives/Planning documents should:
- be stored safely
- be accessible to other health professionals or services providers involved in decision-making about care
- accompany an older person when transferred to hospital.
Communication about any changes to ACPs or ACDs is vital, between any clinicians and aged care workers involved in caring for an older person at home. Refer to your organisation’s policies and procedures on how to manage these documents.
Support the older person in nominating an authorised representative to upload their ACP documents to My Health Record. This portal can be securely accessed when needed.
Advance Care Planning Australia offer free advice, information and interpreter services for health care workers and the community. Assistance is available through the National Advance Care Planning Advisory Service (Ph: 1300 208 582).
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How to build knowledge, confidence and skills in ACP in home care
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- The ELDAC Home Care App is designed to help care workers to provide palliative and end-of-life care to older people at home. The App has six sections:
- Plans for end of life
- What should I say?
- As things change
- When someone is dying
- Supporting families and carers with their grief
- Looking after yourself.
- View the ELDAC Home Care Toolkit educational video on Recognise End of Life, which also discusses advance care planning.
- The ELDAC Home Care App is designed to help care workers to provide palliative and end-of-life care to older people at home. The App has six sections:
- Listen to the ELDAC Podcast – Episode 4: Supported decision-making.
- Complete the Conversation Starters (522kb pdf) by ACPA
- Individually, to gain insight into what it might feel like for older people to reflect on these issues.
- In a role play with a colleague, to gain confidence and skills in exploring and facilitating discussion using these prompts.
- Increase your familiarity with ACP documents and legal requirements in each state or territory.
- Review the palliAGED downloadable Practice Tips on ACP for Nurses (pdf 317kb) and Careworkers (pdf 434kb) and complete your reflections on the second page.
- If it is within the scope of your role to initiate or lead conversations about advance care planning for older people at home:
- Ask to shadow an experienced colleague to observe an Advance Care Planning discussion with an older person and their family or carers. Reflect on the specific skills that your colleague uses to facilitate this conversation. These include rapport building, open questions, active listening, responding empathically to body language and responding to emotional cues.
- Expand your knowledge about Voluntary Assisted Dying (VAD). This topic can arise during ACP conversations. Remember, VAD cannot be requested through an ACP document such as an ACD. A person’s substitute decision-maker cannot request VAD on a person’s behalf.
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- The ELDAC End of Life Law Toolkit has a comprehensive section on Voluntary Assisted Dying.
- Advance Care Planning Australia has a factsheet (329kb pdf) on navigating the topic of VAD in ACP conversations.
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- End of Life Law for Clinicians (ELLC) offers a free online training course in aged care. There are case studies and interactive exercises to improve your knowledge and skills when caring for older people at the end of life. This summary (266kb pdf) provides information about the training modules covered and how to register. If appropriate CPD hours can be claimed. Module 14 End of Life Law in Aged Care explores common legal issues.
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Information for families and carers
Conversation Starters (522kb pdf)
Advance Care Planning Australia
These conversation starters can help families and carers to think about how to begin to talk someone about their values and preferences.
Advance care planning: Being chosen as a substitute decision-maker
Advance Care Planning Australia
This short video explains what it means to be a substitute decision-maker for a family member or carer.
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References
- Australian Government Department of Health and Nous Group Pty Ltd. National framework for advance care planning documents. Canberra (AU): Australian Government Department of Health, May 2021 [cited 12 Feb 2026].
- Advance Care Planning Australia (ACPA). What is advance care planning. July 2025. [cited 12 Feb 2026].
- South Western Sydney Local Health District. My Wishes: Information about advance care planning for residential aged care staff (172kb pdf). SWSLHD My Wishes Advance Care Planning Program. Updated 03 July 2013. [cited 12 Feb 2026].
- Advance Care Planning Australia (ACPA). What is advance care planning? Factsheet for Health Professionals (139kb pdf). January 2024. [cited 12 Feb 2026].
- ELDAC End of Life Law Toolkit. Factsheet: Advance Care Directives. 17 April 2025. [cited 12 Feb 2026].
- ELDAC End of Life Law Toolkit. Overview: Capacity and Consent to Medical Treatment. 3 November 2025. [cited 12 Feb 2026].
- ELDAC End of Life Law Toolkit. Factsheet: Substitute Decision-Making. 3 November 2025. [cited 12 Feb 2026].
Page updated 22 September 2026
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