Advance Care Planning

ACP conversations should be:

• Introduced early, when someone enters residential aged care.
• A routine part of ongoing care planning for an older person.
• 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 then identify which team members within your organisation undertake these conversations.

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 that is private, quiet, and where you are not likely to be interrupted.
• Your approach: Consider simple words that you might use to begin to explore someone’s wishes and preferences. For example: 'We try to talk to everyone who is living here about what they would want if they became very unwell. Have you ever thought about this?'

Other 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. The Discussion Starter is available in several languages.
• The e-REDMAP Framework 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 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.

An ACD 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 ACDs in more detail.

ACP documents may be kept with the person, substitute decision-maker(s), their GP, or the residential aged care provider.

In residential aged care, Advance Care Directives/Planning documents should be:

• be stored safely
• be accessible to team members and other visiting service providers involved in decision-making about care
• accompany an older person when transferred to hospital.

Refer to your own organisation’s policies and procedures when considering how to manage Advance Care Directives/Planning documents within your setting. 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).