Health professionals: roles and responsibilities 

Advance care planning allows health professionals to understand and respect a person's future healthcare preferences, for a time when they become seriously ill and unable to communicate for themselves.

All healthcare professionals and aged care workers have an important role to help with planning and ensuring people have choice in their care. You might want to start the conversation with someone, or they might ask you about the requirements of advance care planning.

Ideally, advance care planning will result in a person's preferences being documented into an advance care directive to help ensure these preferences are respected.

When to introduce advance care planning

Advance care planning conversations should be routine and occur as part of a person’s ongoing healthcare plan. Better outcomes are experienced when advance care planning is introduced early as part of ongoing care rather than in reaction to a decline in condition or a crisis situation.

Read more about triggers for introducing advance care planning and starting the conversation.

Substitute decision-makers

Explain to patients they will need to select a substitute decision-maker(s). This should be someone who is not a paid carer or healthcare provider. Ideally, they will need to be:

  • available (live in the same city or region)
  • over the age of 18
  • prepared to advocate and make decisions clearly and confidently on a person’s behalf when talking to doctors, other health professionals and family members if needed

Learn more about the responsibilities of substitute decision-makers.

Encourage patients to document their plan

After discussing advance care planning with patients, encourage them to document their plan. The processes and names of the relevant documents vary between different states and territories.

Learn more about the process and requirements in your state or territory.

Completing these documents is the best way for people to make their preferences known about the type of treatment they would want if they are unable to participate in decisions and to inform health professionals of these preferences.

Encourage patients to share copies of the documents with their substitute decision-maker, family, friends, carers and relevant health professionals. They should also upload the documents to My Health Record.

Consider the different needs of patients

Australia has a large population with different needs, based on their values, religion, beliefs and preferences. It's important to ensure people receive care that is consistent with these needs.

Culturally and linguistically diverse people

Australia has a rich cultural diversity, with over 300 languages spoken, over 100 religions and nearly 200 countries of origin represented. With these diverse backgrounds come diverse values, some of which may affect an individual’s propensity to engage in advance care planning conversations.

Some aspects of advance care planning may conflict with traditional values expressed by some cultures. But people of all cultural backgrounds may engage in advance care planning.

Start the conversation by asking about the person's beliefs and discussing values with the family. Ask the person if they have any special needs, and involve spiritual leaders in these conversations if the person chooses. Be mindful of the fact that religious and cultural beliefs can differ between families, communities and even individuals.

It's important to avoid cultural assumptions when approaching an advance care planning conversation with patients.

A person’s preferred language is another factor to consider. See our information in a range of languages.

Aboriginal and Torres Strait Islander people

Many Aboriginal and Torres Strait Islander people do not engage in discussions about future medical care and advance care planning. Some may consider discussions about becoming sick or injured, or what will happen towards the end of their life, as ‘family business’ that is not to be discussed with others.

Learn more about considerations for advance care planning with Aboriginal and Torres Strait Islander people.

Lesbian, gay, bisexual, transgender and intersex (LGBTI) people

People identifying as LGBTI people may have special requirements that should be considered when discussing advance care planning. They may not be in close contact with their family, may have no children or may have family who do not respect their life decisions or partner.

Their partner or the person they want to make medical decisions on their behalf may not be recognised as their substitute decision-maker. Encouraging them to appoint a substitute decision-maker and to document their treatment preferences may be helpful.

People with intellectual disability

Many people with intellectual disability have a limited understanding about death and planning for the end of life. However, given the opportunity, most people with intellectual disability want to talk about these things. As with anybody, these conversations can be uncomfortable but with the right support, they can participate in advance care planning conversations without distress.

Talking End of Life is a great source of information for how to teach people with intellectual disability about end of life.

Training and education

Undertaking training and education is the best way to improve your knowledge and confidence to have advance care planning conversations. We support health professionals to learn about advance care planning through a range of online courses, workshops, webinars and information sessions.

Legal and ethical considerations

As a health professional, it's important you understand the laws and ethical principles of advance care planning.

We also recommend signing up to our newsletter to stay up to date with legislative or process changes. 

Responsibilities for healthcare settings

Different healthcare providers have unique responsibilities when it comes to advance care planning.

  • Identify and record details of any existing documents and substitute decision-makers for all patients as part of usual processes
  • Provide patients with information about advance care planning
  • Discuss advance care planning and how it relates to the patient's health issues, condition, treatment options and prognosis
  • Encourage discussion with the substitute decision-maker, and involve the substitute decision-maker and the person's family where possible and appropriate
  • Assist the person to document their plan. If the person has decision-making capacity, use an advance care directive. If the person has diminished or no capacity, the substitute decision-maker may want to document an advance care plan to inform care
  • Check any draft documents and help to clarify wording or intentions
  • Record discussions about advance care planning in medical software and ensure others can access this information if needed
  • Store copies of advance care planning documents in medical records so they are accessible when needed
  • Appropriately share and transfer the person's advance care planning documents between health service providers
  • Encourage the person to give copies to anyone who may be involved in making decisions about their care
  • Ensure that information is available if care is needed 'after hours' (medical deputising or locum services, for example)
  • Review regularly or as needed
  • Activate when needed – use the person's advance care planning documents to inform decisions when they lose capacity

Learn more about advance care planning in general practice.

  • Identify and record details of any existing documents and substitute decision-makers for all residents as part of admission processes
  • Provide residents and families with straightforward information about advance care planning
  • Discuss advance care planning and how it relates to the resident’s health issues, condition and treatment options
  • Involve the resident’s general practitioner in discussions where possible and appropriate
  • Encourage discussion with the person's substitute decision-maker, and involve the substitute decision-maker and the person's family where possible and appropriate
  • Support the resident and their family to document their plan. If the person has decision-making capacity, use an advance care directive. If the person has diminished or no capacity, the substitute decision-maker may want to document an advance care plan to inform care
  • Check any draft documents and help to clarify wording or intentions
  • Record any discussions about advance care planning and ensure others can access this information if needed
  • Store copies of advance care planning documents in the resident’s records so they are accessible when needed
  • Appropriately share and transfer the person's advance care planning documents with their substitute decision-maker, hospital, specialists, in-reach services, Locum, ambulance services
  • Ensure that documents are readily available to inform care decisions, if the person is not able to make their own decisions
  • Encourage review of documents for those with decision-making capacity (triggers include annual care planning, medical assessments, or when conditions change or the resident deteriorates)
  • Use the person's advance care planning documents to inform care decisions, including when the resident’s condition deteriorates
  • Engage with community palliative care and residential in-reach/out-reach services to ensure residents have access to the care they need in their preferred place

Learn more about advance care planning and aged care.

  • Identify and record details of any existing documents and substitute decision-makers for all patients as part of admission processes
  • Receive copies of advance care planning documents from patients or other health services (such as residential aged care facilities or general practitioners); provide clear instructions on how to do this
  • Provide patients and families with straightforward information about advance care planning
  • Discuss advance care planning and how this relates to the patient’s health issues, condition, prognosis and treatment options
  • Encourage discussion with the person's substitute decision-maker, and involve the substitute decision-maker and the person's family where possible and appropriate
  • Support the person and family to document their plan. If the person has decision-making capacity, use an advance care directive. If the person has diminished or no capacity, the substitute decision-maker may want to document an advance care plan to inform care
  • Check any draft documents and help to clarify wording or intentions
  • Record any discussions about advance care planning and ensure others can access this information if needed (such as on discussion cards or e-systems)
  • Store copies of advance care planning documents in the person’s records so they are accessible when needed
  • Create alerts so all staff know that advance care planning documents exist for the person
  • A person's advance care planning documents should inform episodic Goals of Care or medical orders; an advance care directive is legally binding; if preferences have changed, documents may need updating
  • Appropriately share and transfer the person's advance care planning documents with other service providers such as residential aged care facilities or the person's general practitioner
  • Encourage review of documents for those with decision-making capacity (triggers include annual care planning, medical assessments, or when conditions change or the resident deteriorates)
  • Use the person's advance care planning documents to inform care decisions if they lose capacity
  • Identify existing documents and substitute decision-makers for patients
  • Receive advance care planning information from the person's residential aged care facilities and their usual general practitioner
  • Where advance care planning documents exist, discuss how the content relates to the patient’s health issues, condition, prognosis and treatment options
  • Encourage discussion with the person's substitute decision-maker, and involve the substitute decision-maker and the person's family where possible and appropriate in decision-making
  • Record any discussions about advance care planning and ensure others can access this information if needed (such as on e-systems)
  • Create alerts in medical records, so all staff know that advance care planning documents exist
  • Use the person's advance care planning documents to inform care decisions if the patient loses capacity in the context of the current visit
  • Communicate with a person's usual general practitioner and/or care provider regarding their advance care planning documents
  • Involve other services (such as palliative care, residential, in-reach) where required to ensure the person can access care in their preferred place
  • Explain advance care planning to patients/clients and provide them with straightforward information about advance care planning
  • Identify existing documents and substitute decision-makers
  • Encourage discussions with family and substitute decision-makers about advance care planning
  • Record details of advance care planning conversations in records. Share the details with others (with the person's consent) and transfer across settings
  • Refer to advance care planning nurse consultants or champions, general practitioners and palliative care services for support to develop a person’s plan
  • Use the person's advance care planning documents to inform decisions about care if the person loses capacity

Support local primary and community providers by:

  • ensuring access to training and education for advance care planning
  • providing access to resources and tools to implement advance care planning as a part of usual practice
  • facilitating engagement with advance care planning programs and across various healthcare settings
  • supporting improvements in systems for integration and transfer of advance care planning information (e.g. My Health Record)
  • advocating to the state and Commonwealth departments of health regarding issues related to advance care planning that are affecting primary healthcare providers and their patients/clients in the primary health network region

Support local community members by:

  • increasing the knowledge and skills of health and community care providers to support their patients and clients
  • ensuring appropriate advance care planning information is available to the community by working with other health care organisations, service providers, consumer groups, community organisations and local councils
  • advocating to the state and Commonwealth government departments regarding issues identified for your community relating to advance care planning
  • Explain advance care planning to clients and provide them with straightforward information about advance care planning
  • Provide information about where a person can go for further support if needed
  • Identify existing documents and substitute decision-makers
  • Encourage discussions with the person's family and substitute decision-maker
  • Record details of advance care planning conversations in records
  • Refer to organisational champions, general practitioners and palliative care for support to develop a person's plan
  • Encourage the person to share their advance care planning documents with others involved in their care

Printable resources

We produce a range of printable resources for health professionals. They are designed to be given to patients, shared with colleagues or displayed in your office.

For more printable resources, see our range of support materials available to print or order.