Advance Care Planning

Key points

  • Advance care planning (ACP) is a conversation about how a person wishes to be treated under circumstances in which they are not able to speak for themselves. The aim of advance care planning is:
    • To support patients’ autonomy and decision making
    • To prevent them from receiving unwanted treatments, and
    • To help ensure their care is consistent with their values.
  • Recognise that many patients expect their doctor to take the initiative in raising the topic of their preferences about future care.
  • An informed advance care plan requires an understanding by the patient of their own health problems, and also about the realistic implications of the possible treatment options. Competence and capacity should be considered.
  • An advance care plan may consist of:
    •  a discussion between a patient and their doctor about their values and wishes (for example, 'I prefer not to have any extraordinary treatment that would prolong my dying') OR
    • the formal or informal choice of a person to be a substitute decision maker, OR
    • writing an advance care plan, OR
    • a combination of these.
  • Useful Tip

Advance care planning can be as simple as discussing a person’s wishes and ensuring that the family or other substitute decision maker is aware of these wishes. Make sure they are noted in the clinical record.

  • Documentation helps ensure that an advance care plan will be respected. Australian states all have different legal frameworks, and some provide a specific document for recording advance care plans.
  • Even when patients have difficulty acknowledging that they may be deteriorating, or discussing poor prognosis, it is still possible to help them to make an advance care plan - in terms of planning for the 'what ifs'.

Communication for ACP - Guidelines for end-of-life care and decision making

These guidelines set out a process for reaching end-of-life decisions. This process promotes communication among the treating team and with patients and families, supports compassionate and appropriate treatment decisions, fairness, and seeks to safeguard both patients and health professionals. It suggests strategies to reduce or prevent conflict regarding these decisions.

Ref: NSW Department of Health. Guidelines for end-of-life care and decision making (174kb pdf). North Sydney: NSW Department of Health; 2005. 
From: NSW Department of Health

Links and resources - Documents for ACP, by state / territory

Each state and territory has its own local policies about ACP. They include forms for advance directives, policy documents, and information about the legal aspects of ACP for each state and territory.

From: Advanced Care Planning Australia

Making an advance care plan

You can find information about making an advance care plan. This is a planning process that lets other people know in advance your wishes about healthcare if you ever become too unwell to make decisions or speak for yourself.

Ref: Advance Care Planning Australia. The advance care planning process [Internet]. 2020 [cited 2020 Dec 11].
From: Advance Care Planning Australia


Last updated 14 January 2021