Guiding the conversation
Advance care planning conversations should be seen as a normal part of life and of a person’s ongoing healthcare plan. Workers in palliative or aged care and healthcare professionals are in an important position to help with planning. You might want to start the conversation with someone, or they might ask you about the requirements of advance care planning.
Before you can talk about advance care planning, you should become familiar with your state's requirements. You can also undertake training, such as Advance Care Australia's Learning modules.
A person is guided to make an advance care plan in the following five steps:
1. Help them think about their values
Encourage the person to think over what is most important to them in life, based on their values and goals. They should consider various medical treatments and their possible range of outcomes. This step involves the person getting information from family, healthcare professionals, spiritual advisers, therapists and support groups.
2. Talk about their values
Discuss the person's values and healthcare preferences with them. Encourage them to talk to their family and anyone else involved in their healthcare, such as doctors or carers. The person need to know that their choices are understood by everyone.
3. Help them choose a substitute decision-maker
As part of their plan, a person may nominate a substitute decision-maker, who would make decisions for the person if they were no longer competent. The substitute decision-maker should be involved is all advance care planning conversations that the person has with their healthcare team. The substitute decision-maker should be:
- someone they trust
- available (ideally living in the same city or region)
- over the age of 18
- prepared to communicate clearly and confidently on the person's behalf
A person can legally appoint someone in their state using a form. Depending on their state or territory, a substitute decision-maker may also be referred to as:
- an enduring guardian
- a medical enduring power of attorney
- an agent
- a decision-maker
4. Encourage them to write their plan down
A written plan helps ensure that a person's preferences will be respected by if they can no longer communicate or make decisions. A person can create their own advance care plan or they can use a form relevant to their state or territory. They should share this document with:
- their substitute decision-maker
They can also make copies and store them with:
5. Suggest that they review their plan
An advance care plan is a living document and the process is an ongoing conversation. A person should review their advance care plan every year or if there is a change in their health or personal situation. If a person wants to update their advance care plan, they should write a new one and then distribute and discuss it with the people who had the previous plan.