Advance Care Planning

Advance care planning (ACP) involves talking about and documenting a person’s values, preferences, and decisions about future care including end of life. It helps ensure an individual’s choices are known if they are unable to communicate. You can introduce and encourage these discussions at different points along the older person’s care journey.

Read the supporting evidence

What I can do

ACP helps people plan ahead. Consider raising it:

If they have a serious illness, early dementia, or signs of decline
After a hospital stay, new diagnosis, or moving into residential aged care
If they express concerns about the future or recall difficult past experiences with death and dying.

Creating the right environment for these discussions is important. To help people feel at ease:

Choose a quiet, private space and allow enough time
Provide hearing aids, communication aids, or an interpreter if needed
Involve a trusted friend or family member if they wish.

Clear documentation helps ensure wishes are respected. You can support this by:

Helping the person clearly state their preferences
Encouraging them to share their plan with family and healthcare providers
Storing ACP documents in an accessible place such as My Health Record.

Tips for Careworkers: Advance care planning

Tips for Nurses: Advance care planning

What I can learn

The palliAGED Practice Tip Sheets give helpful guidance on supporting older people with ACP near the end of life. There is a version for nurses as well as careworkers.

You can also build your skills with these eLearning modules (free: registration required):

Advance care planning module from PalliBytes
Advance Care Planning Australia courses and webinars
The Advance Project courses that focus on ACP for people with dementia

Access these resources to understand the legal aspects of ACP:

The ELDAC End of Life Law Toolkit
Local guidelines for ACP laws in each State and Territory from Advance Care Planning Australia
Module 14: End of Life Law in Aged Care (60 mins) from the End of Life Law for Clinicians (free: registration required)

What I can give

If an older person, their family or carers wishes to learn more about ACP, these resources may help:

What is advance care planning? (182kb pdf) from Advance Care Planning Australia
Substitute decision-makers (259kb pdf) from Advance Care Planning Australia
What matters to me: Conversation guide from the Department of Health and Aged Care

Older people, their family and carers can also receive support and guidance from the National Advance Care Planning Support Service:

call 1300 208 582
e-mail acpa@advancecareplanning.org.au

What I can suggest

Ensure processes are in place to make ACP documents accessible by:

Using standardised forms
Storing them in a safe, accessible system (e.g. My Health Record)
Having clear processes for updating and sharing them with the full care team.

Staff confidence in ACP improves with proper training. Your team can:

Offer training using the guides from Advance Care Planning Improvement (ACPI) Toolkit
Develop scripts or templates to help staff start ACP discussions
Provide mentoring or role-playing exercises to build confidence in having sensitive conversations.

Making ACP part of routine care planning improves outcomes. Suggest:

Using the Advance Care Planning: Aged Care Implementation Guide (2023) (838kb pdf)
Starting ACP discussions early in an older person’s care journey
Returning to discuss preferences whenever care needs change.

Page updated 02 January 2025