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 cognitive disability
Many people with cognitive disability have a limited understanding about death and planning for the end of life. However, given the opportunity, most people with cognitive 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. Learn more about advance care planning and disability.
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.
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- Explain advance care planning to patients/clients and provide them with straightforward information about advance care planning.
- Identify existing documents and substitute decision-makers, if available.
- Encourage discussions with family and substitute decision-makers about advance care planning.
- Access advance care planning documents and how to create a plan.
- Support the clients 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.
- Note the only valid way to appoint a substitute decision-maker is using prescribed statutory forms for the relevant state or territory.
- Before choosing to use a commercial software or digital product, check that it emphasises the need for the person to complete it, allows for a date and signature, and can be witnessed to ensure the person had capacity and completed it voluntarily.
- Note details of advance care planning conversations in records. Share the details with others (with the person’s consent) and transfer across settings.
- Check any draft documents and help to clarify wording or intentions.
- Have advance care planning documents witnessed to ensure the voluntary completion of documentation.
- Refer to advance care planning nurse leads, general practitioners, and/or the National Advance Care Planning Support Service 1300 208 582 for support to develop a person’s plan.
- Ensure advance care planning documentation is stored in the person’s health record and/or My Health Record.
- Encourage the person to share their advance care planning documents with anyone involved in making decisions about their care.
- Use the person’s advance care planning documents to inform decisions about care if the person loses capacity.
- Ensure access to training and education for advance care planning.
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- Discuss advance care planning and how it relates to the patient's health issues, condition, treatment options and prognosis, and provide them with straightforward information about advance care planning.
- Identify existing advance care planning documents and substitute decision-makers.
- Encourage discussion with the substitute decision-maker, and involve the substitute decision-maker and the person's family where possible and appropriate.
- Utilise the advance care planning HealthPathways to guide care.
- Assess the person’s capacity to participate in advance care planning and/or the documentation of an advance care directive and encourage them to create a plan. If the person has diminished or no capacity, the substitute decision-maker may want to document an advance care plan to inform care.
- Note the only valid way to appoint a substitute decision-maker is using prescribed statutory forms for the relevant state or territory.
- Record details of advance care planning conversations in the health records.
- Refer to an advance care planning facilitator and/or the National Advance Care Planning Support Service 1300 208 582 for support to develop a person’s plan.
- Check any draft documents and help to clarify wording or intentions.
- Witness their advance care planning documents to ensure the voluntary completion of documentation.
- Encourage the person to share their advance care planning documents with anyone involved in making decisions about their care
- Appropriately share and transfer the person's advance care planning documents between health service providers
- Ensure advance care planning documentation is stored in the person’s health record and/or My Health Record.
- 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 medical treatment decisions when they lose capacity.
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- 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.
- Encourage discussion with the patient’s substitute decision-maker, and involve the substitute decision-maker and the person’s family where possible and appropriate.
- Refer to an advance care planning facilitator, their general practitioner and/or the National Advance Care Planning Support Service 1300 208 582 for support to develop a person’s plan.
- Support the person and family to document their plan. If the person has decision-making capacity, use an advance care directive and encourage them to create a plan. 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.
- Have advance care planning documents witnessed to ensure the voluntary completion of documentation.
- Record any discussions about advance care planning and ensure others can access this information if needed (such as on discussion cards or e-systems).
- Ensure advance care planning documentation is stored in the person’s health records and/or My Health Record.
- 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 when conditions change or the patient deteriorates).
- Activate when needed – use the person’s advance care planning documents to inform care decisions if they lose capacity.
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- 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 and encourage them to create a plan. If the person has diminished or no capacity, the substitute decision-maker may want to document an advance care plan to inform care.
- Note the only valid way to appoint a substitute decision-maker is using prescribed statutory forms for the relevant state or territory.
- Refer to general practitioners and/or the National Advance Care Planning Support Service 1300 208 582 for support to develop a person’s plan.
- Check any draft documents and help to clarify wording or intentions.
- Have advance care planning documents witnessed to ensure the voluntary completion of documentation.
- Record any discussions about advance care planning and ensure others can access this information if needed.
- Before choosing to use a commercial software or digital product, check that it emphasises the need for the person to complete it, allows for a date and signature, and can be witnessed to ensure the person had capacity and completed it voluntarily.
- Store copies of advance care planning documents in the resident’s records and/or My Health Record 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.
- Encourage the resident to share their advance care planning documents with anyone involved in making decisions about their care.
- 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 and if they lose capacity.
Learn more about advance care planning and aged care.
Learn more about advance care planning and disability.
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.
- Getting started guide (for patients) [PDF 4534.82 KB]
- Advance care planning factsheet for healthcare professionals [PDF 177.36 KB]
For more printable and downloadable resources, see our range of support materials.