Advance Care Planning

ACP conversations should be:

• Introduced early in care relationships.
• A routine part of ongoing care planning for an older person.
• Alilgned with the older persons expectations for care.
• Reviewed regularly, especially:
  • where the older person expresses a wish to update or change their plan
  • after an illness, accident, or admission to hospital
  • when an illness progresses or someone is deteriorating.

If facilitating discussions about ACP is not within the scope of your role, identify who may be most appropriate to undertake these conversations. This may be a General Practitioner, care partner or a member of the specialist palliative care team.

Making an Advance Care Directive and ACP is voluntary. An older person can choose not to have a Directive or planning document if they prefer.

Consider:

• The person: Ideally, the older person should be medically stable, comfortable, and accompanied by their substitute decision-maker(s), family or carers.
• The location: Find a space within the home that is private and quiet to avoid interruptions.
• The approach: Consider simple words that you might use to begin to explore someone’s wishes and preferences. For example: 'We often talk to people about what they would want if they became more unwell. Have you ever thought about this?'

Consider conversation starters and useful information:

• Talk about your choices by Advance Care Planning Australia, or the brief What is Advance Care Planning - Factsheet for Health Professionals (139kb pdf).
• What Matters Most Discussion Starter and Facilitator Guide by Palliative Care Australia has been designed for older people using aged care services and is available in several languages.
• The REDMAP Framework (928kb pdf) provides a 6-step guide to future care planning conversations. REDMAP stands for: Ready, Expect, Diagnosis, Matters, Actions and Plan.

There are relevant forms and templates that can be used to support planning. However, forms and requirements vary between states and territories for ACP, ACDs, and appointing substitute decision-makers. Your organisation or service may also have relevant documents and resources you can use to facilitate ACP.

• To learn about ACP documents, including ACDs in your state or territory, go to Advance Care Planning Australia’s Record Your Choices.
• Go to the ELDAC End of Life Law Toolkit for helpful information and resources on ACDs, case studies and mythbusters.
• The ELDAC Dementia Toolkit includes ACP resources to support people living with dementia.
• The ELDAC Our Diversity webpage has information and resources on supporting ACP for diverse groups.

ACP documents may be kept with the person, substitute decision-maker(s), their GP, or their home care provider.

Advance Care Directives/Planning documents should:

• be stored safely
• be accessible to other health professionals or services providers involved in decision-making about care
• accompany an older person when transferred to hospital.

Communication about any changes to ACPs or ACDs is vital, between any clinicians and aged care workers involved in caring for an older person at home. Refer to your organisation’s policies and procedures on how to manage these documents.

Support the older person in nominating an authorised representative to upload their ACP documents to My Health Record. This portal can be securely accessed when needed.

Advance Care Planning Australia offer free advice, information and interpreter services for health care workers and the community. Assistance is available through the National Advance Care Planning Advisory Service (Ph: 1300 208 582).